ADDITIONAL CARD REQUEST/CARD TERMINATION (only applicable if your employer has chosen this option)
Spouse Name:
SSN:
Date of Birth
/ /
Address to issue card (if different than participant)
Telephone: Is this person now, or has this person ever been enrolled in Medicare*? Yes No
If “Yes,” you must provide this person’s Medicare Claim Number (HICN):
All Dependents must be over the age of 18 in order to receive the AmeriFlex Convenience Card
®
REQUEST FOR SERVICE FORM continued . . .
□ □
Add
Term
DIRECT DEPOSIT- AUTHORIZATION AGREEMENT FOR ACH DEBITS/CREDITS
Depository Name:
Account Name:
City: State:
Zip:
Routing Number:
Account Number:
Checking Account Savings Account
SELECT ONE
DateEmployee Signature
AMERIFLEX 302 Fellowship Road, Suite 100, Mount Laurel, NJ 08054 Toll Free: 888.868.FLEX (3539) Fax: 800.282.9818 www.flex125.com
Please note: Only Benefit/Election amount changes require Employee AND Employer approval.
(always 9 digits)
CHECK EXAMPLE
routing number account number check number
If you would prefer, please attach a voided check.
DateEmployer Signature
If you wish to have an AmeriFlex Convenience Card® issued for a spouse or dependent, please be sure your spouse or
dependent meets the IRS eligibility guidelines below:
1. For federal tax purposes, a “spouse” is defined as, “. . . a person of the opposite sex who is a husband or wife.” Same sex domestic partners are not
considered spouses for purposes of FSA administration. A person residing in the employee’s home, who the employee provides over half of their support, who
is not the employee’s spouse, under applicable state law and is not a family member, is considered a dependent under Internal Revenue Code 152.
2. For federal tax purposes, a “dependent” includes any relative of the participant for whom the participant provides over half of their support for the calendar
year. “Relative” includes children, parents, stepchildren, stepparents, siblings, aunts, uncles, cousins, and in-laws of the participant. Relatives do not need to
reside with the participant in order to be dependents, nor do they need to be of a certain age or infirmity; they need only to be persons for whom the
participant has provided over half of their support.
Dependent Name:
SSN:
Date of Birth
/ /
Address to issue card (if different than participant)
Telephone: Is this person now, or has this person ever been enrolled in Medicare*? Yes No
If “Yes,” you must provide this person’s Medicare Claim Number (HICN):
□ □
Add
Term
□ □
□
□
Dependent Name:
SSN:
Date of Birth
/ /
Address to issue card (if different than participant)
Telephone: Is this person now, or has this person ever been enrolled in Medicare*? Yes No
If “Yes,” you must provide this person’s Medicare Claim Number (HICN):
□ □
Add
Term
□
□
This agreement is subject to the terms of my Company's Flexible Benefits Plan, as amended from time to time, and as governed under applicable laws. This amendment
revokes any prior election and agreement relating to such plan(s). By signing this form, I agree to the terms and procedures of my Company's Flexible Benefits Plan.
Upon receipt, the Federal Reserve requires 14 business days to perform the initial approval of the ACH information. After this time, AmeriFlex will be directly depositing all
claim reimbursements into the bank account provided two days after every processing date determined by your employer.It may take up to 5 business days to have your
reimbursements appear in your account, depending upon the automated clearing house utilized by your bank. We suggest that you contact your bank to confirm when
these funds become available in your account. AmeriFlex shall not be responsible for any
checks or other debt payments you make whereby you have assumed these
funds are available.
I, hereby authorize AmeriFlex, LLC, hereafter called ADMINISTRATOR, to initiate debits and/or credits to or from my Bank Account indicated below at the depository
financial institution named below, hereinafter call DEPOSITORY, and to debit and or credit the same to such account with the agreement that the only debits to be made
will be for the sole purpose of correcting a pri
or FSA reimbursement error. I acknowledge that the origination of ACH transactions to or from my account must comply
with the provisions of U.S. law. Depository information will be kept on file for future claims. Please complete a new form if your Bank or Account information change.
*Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) requires AmeriFlex to report certain HRA enrollment data to the Centers
for Medicare & Medicaid Services.
