The fastest way to file a reimbursement claim is through your online account, or on our mobile app, Download and complete a Dependent Care Reimbursement/Provider Acknowledgement Form and include all applicable documentation.

Services provided by a child care or elder care center must comply with all state and local laws to be an eligible reimbursement expense. You can be reimbursed only for services that have been received. Option 1: Go Paperless! You won’t need to complete paper forms anymore. Just submit claims online at www.mybenefitwallet.com.

Please complete the following information if you are not able to get a receipt/invoice with the info below from your daycare provider. By signing this form I agree to have my account reduced by the amount requested. This claim for reimbursement is only for expenses incurred by eligible plan participants during the plan year.

To submit a claim to pay a Provider directly, please visit the Ameriflex Participant Portal. Complete all applicable sections, sign and date. Upload the completed claim form in the Participant Portal or email the form to Ameriflex. Please allow 2-3 business days for claims processing from the date the claim is received.

Dependent Care Claim Form (DCA) Please complete this form to submit a DCA claim. Claims may also be submitted online in our Health Benefit Solutions Portal. Mail completed form to: P.O. Box 82518 Lincoln, NE 68501-2518 Questions about this form? Call 844.472.6567

Download Recurring DCA Claim Form.pdf

Please send the completed claim form and detailed bills/ EOBs to: Email: [email protected] Fax: 877-747-8564

2022年4月12日 · Filing Dependent Care Account (DCA) claims may feel like a confusing or stressful (or both) process, but it doesn’t have to be. As part of an ongoing series to address common questions about claim forms, here are some solutions for frequently asked questions we hear, regarding the DCA claim form.

Please complete the information below and attach corresponding bills or receipts with dates of service for each listed provider. I certify that I and/or my eligible dependents have incurred the …

Submission Instructions: To submit this form please click the print and sign buton below after filling out all required fields, or download the form from our website and print it out to manually fill it in and either email, or fax it to the above contact information.