Get Claim Dependent Care Form 2010-2024

After you link a bank account to your HSA, we'll send a deposit of less than $1.00 (and matching withdrawal) to your bank account. This process can take up to two business days, not including Saturdays, Sundays or holidays. Once you see the deposit in your bank account, make note of the amount.

Payflex is a game-changing flexible payment solution. Customers buy goods through your site but only have to pay 25% of the cost of their goods upfront. The remaining 75% is then split into three instalments and paid off over 6-weeks. In essence, you are offering your customers a form of instant credit.

If not offered, you can easily be reimbursed from PayFlex for any money you spend out of pocket on qualified expenses, by taking a picture of your receipt and uploading through our mobile app or member website.

Reimburse employees with tax-free dollars Employees can get money back, tax-free, for out-of-pocket eligible health care expenses, up to a fixed dollar amount each year. Employers fund the account, but it doesn't count as taxable income. That means employees use tax-free dollars to pay for certain health care expenses.

Mileage – On the claim form, enter the total number of miles as a separate expense. Multiply the round trip miles by the per-mile medical rate that the IRS allows. You'll need to include documentation of the medical care with the claim. This can be an EOB or itemized receipt.

If you have a PayFlex FSA or HRA, you can use the app to submit a claim to pay yourself back for an eligible expense you paid out of pocket. After you log in to the app, select Manage to get started. To send documents with your claim, simply take a picture and upload it through the app.

Call PayFlex at 1 (844) 729-3539.

Go to payflex.com and click Documents & Forms at the top of the page. Select Administrative Forms and click Flexible Spending Account Claim Form. Complete all fields of the form. Sign and date the form. • Mail or fax your completed claim form and supporting documentation to PayFlex.