Office Use Only / Date Processed Processed by Client PrimeFlex Form 20 Health Reimbursement Arrangement Claim Form PLEASE COMPLETE THIS FORM AND FAX IT ALONG WITH COPIES OF YOUR EOB and/or RECEIPTS TO PRIMEFLEX AT 877-6FAX-HRA. Employee Signature Date // Retain the original receipts and a copy of this form for your records. For Tax Purposes Use only for expenses incurred in the same plan year for yourself or members of your family who are dependents. PrimeFlex HRA Claims 1487 Dunwoody Drive West Chester PA 19380 877. 769. 3539 primeflexhra primepay. To be completed by employee Employee Information Please print clearly PLEASE CHECK HERE IF THIS IS AN ADDRESS CHANGE Name Last First Middle Street Social Security Number City Date of Birth State Zip Code Employer Work Telephone Number E-mail Home Telephone Number PLEASE ISSUE PAYMENT DIRECTLY TO THE MEDICAL PROVIDER S OF SERVICE LISTED BELOW. I CONFIRM THAT I HAVE COMPLETED ATTACHED THE PROVIDER PAY FORM OR INCLUDED THE MEDICAL INVOICE....
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How to fill out the PrimeFlex 20 online
Filling out the PrimeFlex 20 form is essential for claiming health reimbursement arrangement expenses. This guide will provide you with clear and straightforward steps to complete the form accurately and efficiently.
Follow the steps to complete the PrimeFlex 20 form accurately
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by providing your employee information. Clearly print your name, address, Social Security number, date of birth, email address, and phone numbers. Ensure all fields are filled accurately to avoid processing delays.
- If there is an address change, check the box provided. This ensures that your updated information is recorded for future correspondence.
- Next, indicate your employer's name and work telephone number to help with verification during the claims process.
- In the section regarding payment, confirm whether you require payment directly to medical providers. Attach the provider pay form or include the medical invoices for each provider necessitating direct payment.
- List eligible expenses for reimbursement. For each item, provide a brief description, indicate the family member if applicable, the date incurred, total amount of the claim, and the amount you are claiming. Remember to attach appropriate receipts and explanations of benefits (EOBs) on a separate piece of paper.
- Carefully read the certification statement at the bottom of the form. By signing and dating the form, you affirm the accuracy of the information provided and that the expenses were incurred while you were covered under the plan.
- Finally, save your changes, and consider downloading, printing, or sharing the completed form as needed. Retain the original receipts and a copy of this form for your records.
Complete your claims efficiently by filling out the PrimeFlex 20 form online today!
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