Follow the steps to complete your form effectively.

1. Click ‘Get Form’ button to access the Claim Reimbursement Form and open it in an editor.
2. Complete the employee information section clearly. Fill in your full name (last, first, middle), social security number, street address, city, state, zip code, contact numbers, and email address.
3. Indicate if there is an address change by checking the corresponding box.
4. Select your account type (e.g., HRA, FSA) and describe the expense you are claiming.
5. List any family members associated with the expenses, along with the dates of service and the amount of each claim.
6. If requesting direct payment to a medical provider, check the box and ensure you have filled out the provider's information, including their name and address.
7. For dependent care claims, provide details such as tax ID or social security number, dependent name, service dates, and the amount. Ensure the dependent care provider's signature is included with the date.
8. Review all sections for accuracy. Confirm that you are a participant in the plan and all claims are qualified and accurate.
9. Sign and date the form at the bottom.
10. Submit the completed form along with all required supporting documentation to PrimeFlex via fax, email, or mail as specified.

Start filling out your Claim Reimbursement Form online today to ensure timely processing of your claims.