Flexible Spending Account
Claim Form
Health Care & Dependent Care
Mail or Fax completed form and documentation to:
PayFlex Systems USA, Inc.
PO Box 4000
Richmond, KY 40476-4000
Fax: 1-888-238-3539
Page 1 of
1-844-729-3539 (TTY: 711)
To help avoid claim processing delays, 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 or by using the PayFlex Mobile
®
app?
To get started, log in to the mobile app or your member website which may also be accessible via Aetna Navigator
®
.
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 eligible dependents)
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.
Patient Name
Type of Service
(deductible, dental, medical,
orthodontia, over the counter,
pharmacy, vision)
From Date of Service
(not payment date)
MM/DD/YYYY
To/Thru Date of Service
(not payment date)
MM/DD/YYYY Amount Requested
$
$
$
$
Total
$
**If more lines are needed, please complete another form.
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.**
Exact Dates of Service
From
MM/DD/YYYY
To
MM/DD/YYYY Amount Requested
Qualifying Person’s (Dependent’s)
First and Last Name
(Please Print)
Age
On Service
Date
Qualifying person (Dependent) 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
es.
$ Yes
$ Yes
$ Yes
$ Yes
Total $ *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 (Dependent’s) First Name)
Name (Must be printed)
Relative: Yes No
Provider Signature
Caregiver Information/Certification
(Note: This is for a second caregiver, if you have more than one.)
My signature certifies that I have provided the services for these expenses for
(Qualifying Person’s (Dependent’s) First Name)
Name (Must be printed)
Relative: Yes No
Provider Signature
For Health Care Flexible Spending Account: 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 Health Reimbursement Arrangement (HRA) members:
I understand that an Internal Revenue Service (IRS) rule only lets me use my HRA for eligible individuals if they’re covered by a
compliant group health plan*. I certify that the patient noted on my claim (myself, spouse, or eligible dependent) is covered under my Employer’s group health plan or another compliant group
health plan*. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions. *The group health plan must be compliant with the
Affordable Care Act (ACA). It can’t have annual or lifetime dollar limits on essential health benefits. And it can’t exclude coverage because of pre-existing conditions.
For Dependent Care Flexible Spending Account: I certify that I have incurred the Dependent Care expenses for me and, if married, my spouse to work or attend school. These expenses
are for my Qualifying Person (dependent). 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. This is 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 Internal Revenue Service 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 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.
Member 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.**
PF-4 (3-19)
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