INSTRUCTIONS: Please read carefully and be sure your claim is completed in its entirety to ensure there is no delay in
processing. Please do not use a highlighter on claim form, receipts, or any documents included as backup as this may
cause a delay in processing your claim.
1) Explanation of Benefits (EOB): Your insurance carrier sends you an EOB each time a claim is filed. An EOB indicates your
personal obligation via co-insurance or a deductible.
2) Receipts: Include name of person treated; date expense was incurred; type of service; provider name; and amount of expense.
(IRS does not allow credit card receipts)
1) Complete all applicable sections, sign and date. Services must be incurred in order to be
reimbursed.
2) Attach all required documentation
3) Mail, fax or email the completed claim form (scanned with signature if necessary) to
Ameriflex.
4) Please allow 2-3 business days for claims processing from the date the claim is received.
Direct Deposit: 3-5 business days from the date the claim is processed.
Check Delivery: 7-10 business days from the date the claim is processed.
FSA/HRA Expenses | Acceptable forms of documentation include:
If you participate in both an FSA and an HRA, funds will be deducted from each account based on your employer’s plan
design. If you are
responsible for all or a portion of the insurance deductible before employer HRA funds can be made
available, you must submit an HRA Activation Form with an EOB to Ameriflex once your portion is met as proof of the
deductible status. Once approved, the employer funded HRA will be activated.
Orthodontia Expenses:
Your plan may reimburse advanced expenses for orthodontia made through a payment plan. Please contact your employer
to see if these "up-front" orthodontia expenses apply. Orthodontia expenses require that both of the following be
submitted with the initial claim: (1) proof of payment (e.g. provider bill indicating payments or credit card receipt); (2) a copy
of the signed orthodontia contract (must be signed by both the provider and member), including amount, down payment,
monthly fees and estimated length of treatment.
Dependent Day Care Expenses (Reimbursed only after service is provided) - Acceptable forms of
documentation include:
Receipts including the name of the person for whom the service was provided, date expense was incurred, type of service,
name of provider, amount charged and the provider’s tax ID number/SSN. If you are using a private provider (i.e. babysitter)
the receipt must also include their full name, signature, address and SSN (IRS does not allow credit card receipts or
statements as eligible proof of expense). If you have recurring dependent day care expenses, you can get recurring
reimbursement without having to file a claim after each date of service. To set up a recurring claim, you must provide the
date range of services that will be provided and a note/statement from your provider outlining the schedule of expenses
for the entire period of the recurring claim. Your first expense must be substantiated after the service has been provided
before you can set up a recurring claim.
Commuter/Transportation Expenses:
The IRS does not permit reimbursement for expenses older than 180 days from the date incurred.
To avoid delays in reimbursement, please sign and date this claim form and provide notice of any name or address
change to Ameriflex.
I authorize my account(s) to be reduced by the amount requested. To the best of my knowledge and belief, the statements
on this form are complete and true. I am claiming reimbursement only for eligible expenses incurred by eligible plan
participants during the applicable plan year. I certify that these expenses have not previously been reimbursed by this or any
other benefit plan, will not be reimbursed from any other source and will not be claimed as an income tax deduction. I
also understand that I may be asked to provide further details (i.e. a letter of medical necessity from a medical
practitioner certifying that the expense is to treat or cure a medical condition or a more detailed certification from me). I
understand that if my claim is for expenses incurred during a Grace Period: (1) the expenses will be reimbursed first from
available amounts remaining at the end of the preceding Plan Year and then during the Current Plan Year; (2) claims are
paid in the order in which they are approved; and (3) once paid, a claim will not be reprocessed or otherwise re-
characterized so as to change the Plan Year from which funds are taken to pay it.
Spending Account Claim Form
u You can submit this data via myameriflex
Contact us at myameriflex.com/contact-us
Spending Account Claim Form
SSN:
Employer Name:
Employee Name:
Phone:
Email:
Medical Expense Claims (FSA, or Employer funded HRA)
Dependent Day Care Claims
Account Type
FSA
HRA
Date
Expense Incurred
Name of Person
Receiving Medical Service
Amount
Requested
Dependent Name
Dependent
Date of Birth
Date of Service
From
To
Provider Name Provider
Tax ID #
Type of Service
(Day Care, Pre-K, Day Camp, etc.)
Amount
Requested
Provider Signature or Stamp
(if no receipt is available)
Other Claims
Expense Type
Other
Date(s) of Service
From To
Provider Name
(Name of provider)
Description of Expense
(Any other expenses you may have, etc.)
Amount
Requested
Step 1
Step 2
Employee Signature
Please email, fax, or mail to:
Email
Fax
888.631.1038
Attention: Claims Department
Mail
Ameriflex Claims Department
P.O. Box 269009
Plano, TX 75026
Please do not send original documents. If damaged or lost
during processing, they cannot be replaced.
Date
Form cannot be processed without valid signature
By signing this document I agree to the terms and conditions detailed in the instructions provided on page one.
STEP 3
(ex: PRM, EPR, PKG, etc.)
Provider Name Service Provided
(Physician, Hospital, Dentist, Pharmacy, etc.)
(Co-Pay, Deductible, Dental, Vision, RX, over-the-counter, etc.)
u You can submit this data via myameriflex
Conta
ct us at myameriflex.com/contact-us
