Medical Care FSA Claim Information
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Flex One® Request for Reimbursement Form
Instructions: Please print or type the information below.
FLEX ONE CLAIM FAX: 1.877.353.9256
1. Sign and date form.
4. Allow 48 business hours to check status of reimbursement request.
2. The Medical Care Total requested box must be completed.
3. Receipts attached must be clear and legible.
Please maintain copies of all receipts for your records.
Participant's Social Security Number
Participant's E-Mail Address
By submitting this claim form, I request reimbursement from my Flex One account as listed below. I agree to the Terms and Conditions outlined in my employer’s
Summary Plan Description. I certify and warrant to Aflac that these are eligible medical expenses that I or my dependents have incurred, are not cosmetic in
nature and cannot be reimbursed from any other source. I will maintain copies of all documentation for my records.
Participant's Signature __________________________________________________________________________ Date ____________________________
For Medical Care expenses, an Explanation of Benefits (EOB) from your insurance company or other receipt(s) must be submitted. The EOB and/or attached
bills must contain the following items to be processed and approved:
1. Patient Name
2. Service Provider
3. Description of Service
4. Date(s) Service Was Provided
List each receipt separately in the space(s) below. Use additional forms if necessary. A total must be indicated in the Total block below.
Use the Provider Certification space below only if no receipt is attached. Do not indicate “see attached” in the spaces below.
Description of Service
In lieu of receipts or EOB(s) the provider of the service can certify that t