69.09.300.1 (10/12) © PayFlex Systems USA, Inc.
Flexible Spending Account
Claim Form
Health Care & Dependent Care
Mail or Fax completed form and documentation to:
PayFlex Systems USA, Inc.
P.O. Box 4000
Richmond, KY 40476-4000
Fax: (888) 238-3539
Page 1 of ______
For the hearing impaired, call 1-877-703-5572
To avoid claim payment delay, you must sign, date and complete this form. You must also include supporting documentation.
WAIT! Did you know that you can file a claim online? Log in to www.PayFlexDirect.com
or accessible via Aetna Navigator, select File a Claim under
Quick Links. You can also find instructions online for completing this form.
Member Identification Number:
(Employer assigned number or W ID)
Member Full Name:
(Last Name, First, MI)
Member Address:
(Street, City, State, Zip Code)
Note: If you have an address change, please notify your employer. For security purposes, we can only accept an address change from your employer.
Employer Name:
Health Care Expenses (For you, your spouse and your dependents)
Coordination of Benefits: Do you, your spouse or dependent have coverage under another plan? This includes any medical, dental, prescription or vision plan
other than your primary coverage?
Yes – you must include a copy of the EOB for each date of service No
Automatic Monthly Reimbursement for Orthodontia expenses: To set up automatic reimbursements, check this box. Include a copy of your orthodontia
contract with this form. Note: For automatic monthly reimbursements, you only need to send this form and the contract once.
(deductible, dental, medical,
orthodontia, OTC, RX, vision)
(not payment date)
MM/DD/YYYY
Service
(not payment date)
$
$
$
$
**If more lines are needed, please complete another form. You can get claim forms at www.PayFlexDirect.com or accessible
via Aetna Navigator under
MyPayFlexDirect Resources and select Administrative Forms. Attach the appropriate documentation
Total $
Dependent Care Expenses (Child or Adult) - If your caregiver completes and signs below, you do not need to include an itemized statement.
**If requesting for multiple dependents, each dependent must be listed on a separate line.**
Amount
Requested
(Required)
Qualifying Person’s
First and Last Name
(Please Print)
Age
On Service Date
(Required)
Qualifying person is under age 13
OR is mentally or physically
incapable of self-care due to a
diagnosed medical condition and is
over age 12.**Please check, if yes.
From
MM/DD/YYYY
To
MM/DD/YYYY
$
Yes
$
Yes
$
Yes
$
Yes
$ **You do not need to submit evidence of diagnosed medical condition.
Caregiver Information/Certification: My signature certifies that I have provided the
services for these expenses for ___________________(Qualifying Person’s First Name)
Name (Must be printed)___________________________________________
Relative: Yes No
Provider Signature _____________________________________________
Caregiver Information/Certification: My signature certifies that I have provided the
services for these expenses for __________________(Qualifying Person’s First Name).
Note: This is for a second caregiver, if you have more than one.
Name (Must be printed)_____________________________________________
Relative: Yes No
Provider Signature _____________________________________________
For Health Care FSA: I certify that I, my spouse or eligible dependent have incurred each expense on this form. These expenses are for eligible medical care. They are not for cosmetic
reasons. I understand that “incurred” means the service has been provided.
For Dependent Care FSA: I certify that I have incurred the Dependent Care expenses for me and, if married, my spouse to work. These expenses are for my Qualifying Person. These
qualify as eligible expenses under my plan and are not for educational expenses to attend kindergarten or higher. I understand that “incurred” means the service has been provided.
These are regardless of when I am billed or charged for, or pay for the service. I acknowledge that I will have to report the caregiver’s name, address and Tax Identification Number on
Form 2441.
I have not received reimbursement for any of these expenses. I will not seek reimbursement elsewhere, including from a Health Savings Account (HSA). If I receive reimbursement, I
and (if married) my spouse will not claim these same expenses on our income tax return. I have received and read the printed material for the FSA or Limited FSA plan. I agree to all of
the terms and conditions of the plan. Any person who, knowingly and with intent to defraud, files a statement of claim containing any material false, incomplete or misleading information
is guilty of a crime.
Employee Signature __________________________________________________ Date __________________
**If you are mailing your claim, please keep a copy of this claim form and supporting documentation. We will not return these documents.** REV. 08/2012
click to sign
signature
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