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  • Ameriflex Spending Account Claim Form

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My knowledge and belief, my statements in this Claim Form are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for eligible plan participants. I certify that these expenses have not been previously reimbursed on this or any other benefit plan, will not be reimbursed elsewhere, and will not be claimed as an income tax deduction. I authorize my Flexible Spending Account to be reduced by the amount requested. Employee s Signatu.

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If employees spend more than they contribute, resulting in a net aggregate loss in the employer's plan, Ameriflex will refund the difference back to the employer.

You must have a receipt or an explanation of benefits from your insurance carrier for each claim you submit against your account.

An HRA is funded solely by the employer. Employees use HRA funds for qualified medical expenses using an Ameriflex Debit Mastercard® or by submitting a claim for reimbursement. HRA eligibility can differ by employer depending on their needs and plan configuration.

Submit Your Claim in One of These Ways Log in to your account. ... Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).

They may put a temporary hold on your debit card or request repayment until you can locate and produce appropriate documentation. Or your employer may report unsubstantiated amounts as taxable income on your form W-2.

You are able to roll over up to $500 of unused money in your Health Care FSA to the following plan year. You will forfeit any remaining balance over $500. You have until June 30 (the end of the plan year) to incur expenses, and until September 30 of the following plan year to submit eligible claims.

Option 1: File a claim and reimburse yourself Login to your Ameriflex account with your credentials. Click File a Claim at the top of the page. ... Select Pay myself. ... Click the down arrow under Account Type to locate and select the account from which you are seeking reimbursement. ... Click Upload File.

Remember, to be accepted for a claim, you'll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232