Ameriflex Reimbursement Claim Form

Ameriflex Reimbursement Claim Form

Each care provider in the household needs to complete their own reimbursement form.
Use this form for the following reimbursements:
- Covered Medical Out-of-Pocket Expenses if you paid with your own funds
- Covered Medicare Out-of-Pocket Expenses if you paid with your funds
- Medical Monthly Premium – net monthly premium for qualifying individual plans purchased through the Marketplace (not family plan, not average premium reimbursement)
Ameriflex representatives are also available to assist on the phone Monday - Friday, 5 am - 6 pm, and Saturday, 7 am - 11 am (PST) at 1-888-868-3539.
INSTRUCTIONS

Please read carefully and be sure your claim is completed in its entirety to ensure there is no delay in processing. Please do not use a highlighter on the claim form, receipts, or any other documents included as backup as this may cause a delay in processing your claim.

1) Complete all applicable sections, sign, and date. Services must be incurred in order to be reimbursed.

2) Attach all required documentation. For an Over The Counter (OTC) medicine, please include a copy of your medical provider’s prescription or a pharmacy receipt showing the prescription number.

3) Please allow 2–3 weeks for paper check delivery or 7–10 days for direct deposits from the processing date.

To avoid delays in reimbursement, please sign and date this claim form and provide notice of any name or address change to Ameriflex.

I authorize my account(s) to be reduced by the amount requested. To the best of my knowledge and belief, the statements on this form are complete and true. I am claiming reimbursement only for eligible expenses incurred by eligible plan participants during the applicable plan year. I certify that these expenses have not previously been reimbursed by this or any other benefit plan, will not be reimbursed from any other source, and will not be claimed as an income tax deduction. I also understand that I may be asked to provide further details such as, a letter of medical necessity from a medical practitioner certifying that the expense is to treat or cure a medical condition or a more detailed certification from me.
Carewell SEIU 503 Benefits
Name*

First NameLast Name
Social Security Number*
Ex: 111-11-1111
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Preferred Phone Number*
Please enter a valid phone number.
Email - enter to receive a submission confirmation
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Use this form for the following reimbursements:
- Covered Medical Out-of-Pocket Expenses if you used your own funds
- Covered Medicare Out-of-Pocket Expenses if you used your own funds
- Medical Monthly Premium – net monthly premium for qualifying individual plans purchased through the Marketplace (not family plan, not average premium reimbursement)
Which expense(s) or premium(s) do you need reimbursements for:*

Medical Out-of-Pocket ExpensesMedicare Out-of-Pocket ExpensesMedical Monthly Premium
Medical Out-of-Pocket Expenses

Reimbursed up to $7,165 in 2024. Such as the deductible on your approved Marketplace plan, copayments, coinsurance expenses, and prescriptions.

Please select the month and year, and include the amount you are requesting reimbursement(s) for.

Note: The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medical Out-of-Pocket Expenses: Click the "Add Claim" button below if you need to claim another month/year.*
Medicare Out-of-Pocket Expenses

Reimbursed up to $7,165 in 2024. Such as the deductible on your Medicare plan, copayments, coinsurance expenses, and prescriptions.

Please select the month and year, and include the amount, you are requesting reimbursement(s) for.

Note: The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medicare Out-of-Pocket Expenses: Click the "Add Claim" button below if you need to claim another month/year.*
Medical Monthly Premium

Net monthly premium for qualifying individual plans purchased through the Marketplace.

Please select the month and year, and include the amount you are requesting reimbursement(s) for.

Note: The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medical Monthly Premium: Click the "Add Claim" button below if you need to claim another month/year.*
Include documentation for all years for which you are requesting reimbursements, such as:
- Proof of premium payment
- Explanation of Benefits (coinsurance, deductibles, copayment)
- Prescriptions/drugs receipt
Directions on how to upload files

If you DO have the files online:
1. Click on “Browse Files” on this online form
2. Select the file(s) you would like to attach

If you DON’T have the files online:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form. We can’t read or use blurry photos.
2. Click on “Browse Files” on this online form
3. Select the file(s) you would like to attach
Upload forms and/or documents:*

Cancelof
Participant Signature*

Clear
Use your finger or cursor to sign
Today's Date

MonthDayYear
Expense 1
Expense Type*
For example, out-of-pocket, deductible, copays, prescription reimbursement
INSTRUCTIONS
Date Expense Incurred*

MonthDayYear
Date
Amount Requested*
Do you have additional expenses that you would like to request reimbursement for?*

YesNo
Expense 2 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 2 Incurred

MonthDayYear
Date
Amount Requested for Expense 2
Do you have additional expenses that you would like to request reimbursement for?

YesNo
Expense 3 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 3 Incurred

MonthDayYear
Date
Amount Requested for Expense 3
Do you have additional expenses that you would like to request reimbursement for?

YesNo
Expense 4 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 4 Incurred

MonthDayYear
Date
Amount Requested for Expense 4
Do you have additional expenses that you would like to request reimbursement for?

YesNo
Expense 5 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 5 Incurred

MonthDayYear
Date
Amount Requested for Expense 5
Do you have additional expenses that you would like to request reimbursement for?

YesNo
Expense 6 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 6 Incurred

MonthDayYear
Date
Amount Requested for Expense 6
Do you have additional expenses that you would like to request reimbursement for?

YesNo
Expense 7 Type
For example, out-of-pocket, deductible, copays, prescription reimbursement
Date Expense 7 Incurred

MonthDayYear
Date
Amount Requested for Expense 7
In the area below, please either upload or take a photo of your receipt(s) and/or other supporting documents.
Upload document (for an OTC medicine, please include a copy of your medical provider's prescription or a pharmacy receipt showing the prescription #).*

Cancelof
Take a picture of your document
Please read carefully and be sure your claim is completed in its entirety to ensure there is no delay in processing. Please do not use a highlighter on the claim form, receipts, or any other documents included as backup as this may cause a delay in processing your claim.

1) Complete all applicable sections, sign and date. Services must be incurred in order to be reimbursed.

2) Attach all required documentation (For an OTC medicine, please include a copy of your medical provider’s prescription or a pharmacy receipt showing the prescription #).

3) Please allow 2–3 weeks for paper check delivery or 7–10 days for direct deposits from the processing date.

To avoid delays in reimbursement, please sign and date this claim form and provide notice of any name or address change to Ameriflex.

I authorize my account(s) to be reduced by the amount requested. To the best of my knowledge and belief, the statements on this form are complete and true. I am claiming reimbursement only for eligible expenses incurred by eligible plan participants during the applicable plan year. I certify that these expenses have not previously been reimbursed by this or any other benefit plan, will not be reimbursed from any other source, and will not be claimed as an income tax deduction. I also understand that I may be asked to provide further details (i.e., a letter of medical necessity from a medical practitioner certifying that the expense is to treat or cure a medical condition or a more detailed certification from me).
Telephone
Full name*
Carewell SEIU 503

First NameLast Name
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Ameriflex Reimbursement Claim Form

Carewell SEIU 503 Benefits

Expense 1

INSTRUCTIONS