Get Prime Flex Reimbursement Form - Camanche K12 Ia

This guide provides comprehensive instructions on how to fill out the PRIME FLEX REIMBURSEMENT FORM online. Follow the steps below to ensure that you accurately complete your form for timely reimbursement.

Follow the steps to fill out your reimbursement form online.

1. Press the ‘Get Form’ button to access the PRIME FLEX REIMBURSEMENT FORM and open it in your document editor.
2. Complete the employee information section. Fill in the name of your employer, your name, the last four digits of your social security number or your birth date, and your home address if it has changed.
3. In Section One, provide details for medical expenses. Include the date of service, name of the person who received the service, a description of the expense, and the amount claimed. Ensure that your documentation has the service provider's name, amount owed after insurance, and nature of the service.
4. For prescription claims, be sure to include the prescription tag from your pharmacy as documentation.
5. In Section Two, fill out information for dependent care. Provide the name of the dependent receiving care, the dates of service, the name of the day care provider, and the total amount of dependent care expense. Ensure that you have independent verification for the dates of service and the dollar amount claimed.
6. In Section Three, you must certify the accuracy of your information by signing the form and providing the date of your signature.
7. After completing all sections, review your form for any errors or missing information. Save your changes, and you can then download, print, or share the filled-out form.

Start completing your PRIME FLEX REIMBURSEMENT FORM online today!