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The PayFlex Card®, your account debit card - Aetna

You can pay for an eligible expense with cash, check or a personal credit card. You can then use features online or . through the PayFlex Mobile® app to pay yourself back. You can also fill out a paper form and fax or mail it to PayFlex. Note: Remember to include supporting documentation when you submit your claim. 69.03.620.1 D (7/18)

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Health Savings Account (HSA) Investment Fund List

docs.payflex.com

Bank of NY Mellon’s (BNY) acts as clearing & settlement firm. This listing last updated December 2019. Proprietary Asset Class Definitions Equity funds:

  Health, Account, Lists, Investment, Fund, Savings, Health savings accounts, Mellon, Investment fund list

Swipe your way to smart savings - Aetna

docs.payflex.com

Note: If you don’t respond to the request, your card may be suspended until you either send in the requested documentation or pay back the account. Got questions? Visit payflex.com or call us directly at 1–844–729–3539 (TTY: 711). We’re here to help Monday - Friday 7a.m. - 7p.m. CT, and Saturday 9a.m. - 2p.m. CT. Quick tips

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Welcome to NYC.gov | City of New York

www1.nyc.gov

The Health Care Flexible Spending Account Program is a division of the Office of Labor Relations’ Flexible Spending Accounts Program. HEALTH CARE FLEXIBLE SPENDING ACCOUNT (HCFSA) PROGRAM CLAIMS FORM. nyc.gov/fsa. HCFSA. 1) ... An expense which has been incurred by the participant for qualifying health care expenses provided for an .

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Your Health Care Spending Card Debit MasterCard or …

benefits.cat.com

• It’s connected to your flexible spending account (FSA). • There’s no need to write checks or submit claim forms. • Use it for eligible medical, dental, vision and pharmacy expenses. • Use it for eligible dependent care expenses (if it applies). I’ve lost my card or it was stolen! Call Customer Care immediately at 1-866-755-2648 ...

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Cigna Health Care Reimbursement Request Form

www.cigna.com

claim and we won't be able to pay you back. Read every box. Fill in all the required information on this form. Required information is marked with *. For Cigna Flexible Spending Account, Health Savings Account, or Reimbursement Account (which includes Healthy Awards and Healthy Future Accounts) I declare that:

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Get your money faster. How to Submit Claims

webdocs.asiflex.com

Flexible Spending Account (FSA) Claim Form . Your Name (Last, First, MI) Social Security No. or EID or PIN Your Employer’s Name Address City State Zip Code Dependent Care Flexible Spending Account Claims. Follow the instructions on page 1 and submit correct documentation or have your provider sign below to certify the care provided.

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What do I need to file my taxes?

www.hrblock.com

Expenses paid through a dependent care flexible spending account at work Educational Expenses Forms 1098-T from educational institutions Receipts that itemize qualified educational expenses Records of any scholarships or fellowships you received Form 1098-E if you paid student loan interest K-12 Educator expenses

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Flexible Spending Account (FSA) Claim Form

onlineasap.dbsbenefits.com

Flexible Spending Account (FSA) Claim Form Claim Filing Options Online: File a claim online by logging into your account at www.dbsbenefits.com Fax/Mail: Complete form below and mail or fax to: Diversified Benefit Services, Inc. PO Box 260, Hartland, WI 53029 Fax (262)367-5938 For assistance please call (800) 234-1229. Participant Information

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Flex Elect Reimbursement Claim Form - California

www.calhr.ca.gov

veracity of all information relating to this claim, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, I may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Plan which relate to such expense.

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2021 Publication 503 - IRS tax forms

www.irs.gov

ever, you may still be eligible to claim a credit on Form 2441, line 9b, for 2020 expenses paid in 2021. See the line 8 instructions in the Instructions for Form 2441 for the 2021 Phaseout Schedule. The refundable credit is repor-ted on Form 2441, line 10. The nonrefundable credit is re-ported on Form 2441, line 11. To see if you meet the resi-

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