If you need assistance completing any forms or have any questions, please call Flexible StaffCARE customer service at 1-844-262-6027. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A translation line is available for most languages.
Authorized Representative Form / Formulario de Representante Autorizado
Medical Claim Form (Indemnity Plan) / Formulario de Reclamo de Gastos Médicos (Plan de Indemnización)
Medical Claim Form (MEC Plan) / Formulario de Reclamo de Gastos Médicos (Planes de MEC)
Prescription Drug Claim Form
Prescription Drug Reimbursement Claim Form (MEC Plan)
Wellness and Preventive Care Reimbursement Claim Form
Dental Claim Form
Missed Premium Direct Payment Form / Formulario Para el Pago Directo de Primas no Cubiertas
MEC Plan Missed Contribution Direct Payment Form (For weekly payroll deducted MEC plans only.)
Short-Term Disability/Proof of Loss Form
Term Life / Accidental Loss of Life Claim Form
Vision Claim Form
Access Request Form
Amendment Request Form
Authorization for Marketing (Health Plan)
Authorization Form (Health Plan) (This form is used for psychotherapy notes, chemical dependency and sensitive diagnosis.)
Authorization to Disclose PHI to a Third Party
Complaint Form
Confidential Communication Request
Designation of Authorized Representative to Appeal
Disclosure Accounting Request
Notice of Privacy Practices
Notice of Privacy Practices (Spanish)
Restriction Request