Get Payflex Claim Form

Filing your Payflex Claim Form online can simplify the reimbursement process for your health and dependent care expenses. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to fill out the Payflex Claim Form online

1. Click the ‘Get Form’ button to access the Payflex Claim Form and open it in your preferred editor.
2. Begin by entering your employee name and member number. The member number may be your Social Security Number or an employer assigned number.
3. Next, fill in your employer's name. If you need to make changes to your address, contact your employer’s HR or Benefits department directly.
4. For health care claims, review the instructions provided. If your expense is covered by insurance, submit your claim after you receive the Explanation of Benefits Statement (EOB). Attach a copy of the EOB and any itemized statements from your service provider, if applicable.
5. For expenses not covered by insurance, please include an itemized statement from your provider confirming necessary details, including dates of service and amounts charged.
6. List each service, its date, type (e.g., prescription, dental), and the amount requested in the designated fields.
7. If you are filing claims for dependent day care, complete the relevant section by providing your dependent’s name and age, along with the provider's information, including their Tax Identification Number or Social Security Number.
8. Ensure that you make the necessary certifications regarding the eligibility of your expenses, and provide your signature and date at the bottom of the form.
9. Once you have completed the form, remember to save your changes. You can then download, print, or share the form as necessary.

Complete your Payflex Claim Form online today to ensure timely reimbursement for your eligible expenses.