info@flexfacts.com. FSA General Claim Form Dependent Care Claim Form Direct Deposit Form HIPAA Authorization Form HRA General Claim Form Direct Deposit Form HIPAA Authorization Form HSA How much can I contribute? Deductions are authorized on a yearly basis during the open enrollment period. You will continue to receive communications that are necessary for providing our services. 1200 River Ave, Suite 10E Lakewood, NJ 08701 www.FlexFacts.com. Let us help. To be reimbursed for over-the-counter medications, you must submit your claim with a prescription … %���� You will receive a letter indicating the outcome of the investigation, once a decision is reached. HEADQUARTERS. Tired of looking for receipts, claim forms … endobj Note: Paperless claim submission is only available to PPO participants. 8700 W. Bryn Mawr Avenue, Suite 1010S, Chicago, IL 60631 Phone: 847-699-6900 Fax: 847-699-6906. ... • To file via fax or mail complete a Claim Form and send it along with a copy of the receipt/invoice to: • Flex Facts Claims Department, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, For example, if you are required to pay for all of January's child care expenses on January 1st, you cannot claim the entire month's expense until the end of January. �1.s��-��~���b��>'r��˜�y7�������_Q�GԄ}�E��A�Àȫ2$W���w� You must also include supporting documentation. Last Four Digits of Your Social Security Number Phone. stream Last Employer. • To file electronically, log into your FlexFacts FSA account and follow the instructions. We will maintain the confidentiality of your personal information in accordance with our privacy policy. Employee Name (last name, first name) Social … Flex Facts, 7 Grant Ave, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Flexible Spending Account Claim Form Personal Information Full Name: Last First M.I. Please send this form along with all applicable receipts to: 1200 River Ave, Suite SC, Lakewood, NJ 08701 Fax: 877-747-8564 E-Mail: Claims@flexfacts.com Personal Information E-mail. Contribution Grid for Spouses Qualifying HSA … Download forms for the Employer, Employee, Cobra or HSA. To prove the validity of the claim, the claimant may include a letter, a receipt, an original photograph, and all those physical entities that have to do with … Dependent Care Reimbursement Plan Guidelines Employer provided dependent care assistance is tax-free only if the … To do so, click ‘Manage’ or ‘Opt-out’ on one of the marketing emails you received or click the Opt-out link below and complete the form request. Adjusted claims are not processed through CrossTech and need to be submitted manually. Flex Facts, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Spending Account Claim Form Personal Information Personal Information . endobj 5050 Quorum Drive, Suite 700, New Address: City, State, Zip Claim … Find the most frequently used carrier forms you need right here - just click and print! 4 0 obj Cellphones have become just as vital to business as a land line, which makes cellphone use a legitimate, deductible business expense. Spending Account Claim Form Full Name. Follow these easy steps: 1. a��Sʦ9c! Eligible expenses include day care, baby-sitting, and general purpose … 1200 River Ave, Suite 10E, Lakewood, NJ 08701, www.FlexFacts.com, 877-94-FACTS (32287) HRA Claim Form Personal Information Full Name: Last First M.I. Click here to download Adobe PDF Reader. Before you can access your account, you must register with the site and create a username and password.Test x��]mo�8���@�}�E|�� �$=Y�`�ѷ���nn?�'1Ʊ3�3=�﯊/�$��,+ N,��Yŧ�E��?�V���]��O�����~y��zz�����9���qy�yq��,v�����˷^��nw˧�����e���7E^��"4+�^��������[�y�����7�W$#$/x�������$�4+y.�(��/2�{�:�;�������ͯ�������}�3��_o�]�7�5�Z��l��h͋2�v�����n~�g��a�B� Claim Forms Aetna Medical Claim Form Aetna Vision Claim Form / Instructions Dental Claim Form BeneCardPBF Claim Form FlexFacts Claim Form Enrollment Forms Printable SHIF Enrollment Form. Manual claims are reimbursed via direct … If your address has changed … • To file via fax or mail, complete a Claim Form and send with a copy of the EOB/receipt to: FlexFacts Claims Department, 7 Grant Avenue, Lakewood, NJ 08701 or fax to 877-747-8564. • To file electronically, log into your FlexFacts FSA account and follow the instructions. You can also opt out of marketing communications. 3 0 obj Click on the FSA Eligible Expense Table link at the bottom of the page and enter in Access Code “flex2011”. An HRA is a reimbursement account set up and funded by your employer to cover eligible healthcare expenses. Please send the completed claim form and detailed bills/ EOBs to: Email: claims@flexfacts.com Fax: 877-747-8564 Mail: 1200 River Avenue, Suite 10E, Lakewood, NJ 08701 Medical & Dependent Care Claim Form Additional Debit Card Request Form Complete and remit this form if requesting an additional card for your spouse or any dependents. Details: your health reimbursement arrangement ©2015 FlexFacts 1200 River Ave, Suite 10E Lakewood , NJ 08701 877-943-2287 www.FlexFacts.com How are HRAs and FSAs different? Click here to establish your username and password to manage your account. áéø¦o žƒñ¢ œÌC•5èÂÁJPúË_¬à™‚¦kªÄšª¨ËÅ8#ò#Ô All forms are in PDF format. • Go to: flexfacts.com • At the bottom of the page, click on FSA Eligible Expense Table What about over-the-counter medications? Don’t have an account? All forms are in PDF format. • To file via fax or mail, complete a Claim Form and send with a copy of the EOB/receipt to: FlexFacts Claims Department, 7 Grant Avenue, Lakewood, NJ 08701 or fax to 877-747-8564. %PDF-1.7 Due to the time it takes to gather all the documents relevant to your claim, it may take up to 90 days to … www.flexfacts.com. Contact Us. A Claim Form is a legal document used for submitting a claim. Forgot your Username? 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