eflexgroup.com - COBRA, HRA, MERP, POP, HSA, and FSA Administration

eflexgroup.com, inc.
 Claim Form
2740 Ski Lane • Madison, WI 53713
Phone: 608) 243.8277 • Fax: (608) 245.9342

Notice: All fields marked with an asterisk (*) are required.
Email*
Employee Name*
Employer Name*
SSN

Fill out for change of address only !
Employee
Address
City, State ,
Zip
Phone Number

Check here if you are submitting eflex Convenience Card verification receipts

Directions for using the Claim Form
1. For all reimbursable expenses, copies of all bills/receipts must be attached including who (name & address) rendered the service, description of charge, date and amount of charge.  Cancelled checks are not acceptable receipts.
2.

Please fax, mail or email the documentation to eflexgroup.com, inc. 

2740 Ski Lane, Madison, WI 53713 

Fax: (877) 231.1287

eclaims@eflexgroup.com.
3.

Please fill this form out and choose one of the buttons at the bottom of the form. By choosing “Printer Friendly”, your form will be processed. A printer friendly version will then be displayed on the screen, for you to print and fax to us.

If you choose “Submit Online” you will get a printer friendly version of the form for you to keep for your own reference. The form will then be submitted to the claim department at eflexgroup.com.
Note: The online submission can only be chosen if you have a contract on file with your daycare, orthodonist, or insurance and this is a recurring claim.
If you do not have a contract on file with us, you will need to click "Printer Friendly" on this online claim form and fax with your documentation.

 

Health FSA Check if this is a recurring claim.
If you do not have a contract on file with us, you will need to select "Printer Friendly" and fax with a copy of the contract.


The information on the document must include the following:
  •  Date (s) of service   •  Type of expense (i.e., eye exam)
  •  Amount of the expense incurred   •  Name of the Service Provider.
Date of Service Description Dollar Amount

 
Dependent FSA Check if this is a recurring claim.
If you do not have a contract on file with us, you will need to select "Printer Friendly" and fax with a copy of the contract.
Please provide the following information:
     A statement from the daycare provider listing:
          • Date(s) of Service
          •  Charges
          •  Provider's Signature
     Or Provider's signature on daycare provider letterhead with:
          • Date(s) of Service
          •  Charges
Date(s) of Service Dependent Name Age(s) Dollar Amount
 
Individual Health Premium Account (Attach Policy Information)
Check if this is a recurring claim.
If you do not have a contract on file with us, you will need to select "Printer Friendly" and fax with a copy of the Declaration page from the policy.

 

The Declaration of Coverage page, or other supporting documentation of the insurance policy, must be submitted once each plan year.
It should show:
•  The type of coverage •  Person(s) covered •  The carrier's name
Include a copy of the premium billing notice from the insuring company, indicating:  the period of coverage and amount of the premium due.
Policy Year Description Dollar Amount

Please date and initial the following boxes:
     *   * I certify that the expense reimbursement requested from my accounts were incurred by me (and / or my spouse and / or eligible dependents), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement under my reimbursement plans.  I (or we) will not use the expense reimbursed through this account as deductions or credits when filling my (our) individual income tax return.  Any person who knowingly & with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

      

Reminders

  
• Provide proper documentation for all expenses submitted • Minimum check amount is $ 10.00
• Sign and date the documents to be sent to  eflexgroup.com, inc. unsigned documents  cannot be processed. • Keep the forms and supporting documentation together
• Multiple expenses may be included on one form. If more space is needed, attach additional forms. • Keep copies of everything you submitted to eflexgroup.com If you need copies of your files from eflexgroup.com, a $25.00 fee will be charged.  IRS guidelines require that eflexgroup.com keep records of all claims and correspondence for three years.
• Expenses for medical and daycare services must be incurred prior to reimbursement.