NECA IBEW Flexible Benefits Plan Claim free printable template

Flexible Benefits Plan Claim Form OFFICE USE ONLY Claim Number http //harrisonflex. aibpa.com Employee Information Last Name Print First Name Street Address City Check if new address Social Security Number MI State Phone Number Submit Claims To Harrison Flex Plan 1220 SW Morrison Street Suite 300 Portland OR 97205 Fax 503 228-0149 Zip Date of Birth INSTRUCTIONS Please provide claim patient information. Is the patient Self Spouse Child Other. If other specify NOTE No patient information...

How to fill out harrison flex plan form

How to fill out NECA IBEW Flexible Benefits Plan Claim Form

1. Obtain the NECA IBEW Flexible Benefits Plan Claim Form from the official website or your HR department.
2. Fill in your personal details including your name, address, and member identification number at the top of the form.
3. Indicate the type of expense for which you are claiming benefits (e.g., medical, dental, vision).
4. Enter the date of service for each expense you are claiming.
5. Attach relevant receipts or documentation that support your claim.
6. Complete all required fields and double-check for accuracy.
7. Sign and date the claim form to certify that the information provided is correct.
8. Submit the completed claim form to the address specified in the instructions, either by mail or electronically.

Who needs NECA IBEW Flexible Benefits Plan Claim Form?

1. Any member of the NECA IBEW who has incurred eligible expenses and wishes to receive reimbursement through the Flexible Benefits Plan.

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What is NECA IBEW Flexible Benefits Plan Claim Form?

The NECA IBEW Flexible Benefits Plan Claim Form is a document used by participants in the NECA IBEW Flexible Benefits Plan to submit claims for reimbursement of eligible expenses, such as medical, dental, and vision costs.

Who is required to file NECA IBEW Flexible Benefits Plan Claim Form?

Participants in the NECA IBEW Flexible Benefits Plan who have incurred eligible expenses and wish to seek reimbursement for those expenses are required to file the claim form.

How to fill out NECA IBEW Flexible Benefits Plan Claim Form?

To fill out the NECA IBEW Flexible Benefits Plan Claim Form, participants should provide their personal information, details of the expenses incurred, attach relevant receipts, and sign the form before submitting it as per the instructions provided by the plan.

What is the purpose of NECA IBEW Flexible Benefits Plan Claim Form?

The purpose of the NECA IBEW Flexible Benefits Plan Claim Form is to allow participants to formally request reimbursement for eligible healthcare expenses under the flexible benefits plan.

What information must be reported on NECA IBEW Flexible Benefits Plan Claim Form?

Participants must report their name, Social Security number, type of service, date of service, amount paid, and attach copies of receipts or any other supporting documentation required for the expenses being claimed.