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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? Log in to your member website or mobile app to get started. You can also find instructions online for completing this form.
You can file claims online. You will find the instructions in the Frequently Asked Questions (FAQs) document mailed to you by PayFlex when you became eligible for your RRA. The FAQs are also available on the PayFlex website. Account Holder Full Name (Last Name, First, MI) Social Security Number (Last four digits only) XXX-XX-
Reimbursement Account Claim Form. Fax: 1-844-306-8146 Email: PayFlex_Receipts@alegeus.com. To 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? Log into www.payflexwallet.com. .
Login to the PayFlex member website and under Quick Links select File a Spending Account Claim. You’ll just need to follow the four steps to quickly file your claim. Paper Claim Filing: If you prefer to file your claim manually, follow these steps. Claim forms are available on your member website.
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 payflex.com, also 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)
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?
This form is to be used when your plan allows recurring reimbursements of health care premiums. Recurring Premium requests must be resubmitted each Plan Year, if you have a new policy, if the premium changes or if a policy ends.
