IntegraFlex Online Claim Form

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Welcome to the IntegraFlex Online Claim Form

**PLEASE NOTE**

If you receive check reimbursements and your address has changed from the address you gave for enrollment. You MUST log into your portal and update your address BEFORE submitting a claim. Click HERE to be directed to the portal homepage.

Let's make sure you have one (1) of the following IRS Acceptable Forms of Documentation Required:

Note: All other forms of documentation are NOT acceptable; please do NOT send them.

1. Explanation of Benefits (EOB) or Itemized Billing Statement for services rendered.


2. The EOB or Itemized Billing Statement should provide the following information:

--Provider Name & Address--

--Patient's Name--

--Date of Service when services were rendered--

--Description of the services rendered--

--The Billed amount for services rendered--


Note: Estimates for services that have not yet been incurred CANNOT be accepted.  Be sure to keep a copy of your EOB or Itemized Billing Statement on file at all times.

   

To help ensure your claim gets processed as quickly as possible, please enter your Employer's Name down below.

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Please enter your LAST Six (6) numbers of your SSN
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It is the last 6 digits of your Social Security Number
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Employee Name

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Claim Information

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Which expense would you like to claim first?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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Would you like to add another Parking or Transit/Commuter claim?

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**Please Read**

If you also have available funds in an FSA, any $ amount you are responsible for, that is not reimbursable under your HRA, will automatically be reimbursed from your FSA. Please specify in the notes section if you DO NOT want reimbursement out of your FSA.
Dependent Care Claim Instructions: If you are submitting a "recurring" dependent care claim, a completed electronic Dependent Care Claim Form and an IntegraFlex Dependent Care Contract MUST be submitted. The contract can be found by clicking here.

Have you received an email from us?


If you have received a request for "Your Recent IntegraFlex Benefits Card Purchase(s)/Transaction(s)" email, We strongly recommend that you submit your documentation by replying to that email.

Have you received a letter from us by U.S. Mail?


If you have received a request for "Your Recent IntegraFlex Benefits Card Purchase(s)/Transaction(s)" by U.S. Mail, please add a scanned copy of the barcode from our letter that you received, to your upload.

Please check the box if a Barcode is in your upload file.

You can add multiple files by dragging and dropping or by selecting 'Browse'.

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CERTIFICATION AND AUTHORIZATION:

The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Employer’s Commuter Benefit Program with respect to such expenses and that all expenses for which reimbursement is claimed by submission of this form were incurred for any parking on or near the business premises of the Employer, on or near a location from which participant commutes to work, and/or for regular daily direct commute from home to work and return and that the expenses have not been reimbursed and that the participant will not seek reimbursement from any other plan for these services. The undersigned understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under this Program, the undersigned may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Program which relate to such expense.
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CERTIFICATION AND AUTHORIZATION:

The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Employer’s Benefit Program with respect to such expenses and that all expenses for which reimbursement is claimed by submission of this form were incurred within the Benefit Plan Year  and that the expenses have not been reimbursed and that the participant will not seek reimbursement from any other plan for these services. The undersigned understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under this Program, the undersigned may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Program which relate to such expense.
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