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An independent licensee of the Blue Cross and Blue Shield Association FLEXSHARE BENEFITS AUTOPAY AUTHORIZATION This authorization will allow certain claims processed through your Blue Cross Blue Shield of Wyoming group health insurance policy to be automatically withdrawn from your Medical Flexible Spending Account or Health Reimbursement Account. Claims will be extracted from the claims processing system weekly and loaded into the Flexible Spending Account processing system. Those claims will AutoPay through your HRA without submitting paper reimbursement forms and documentation. Eligible claims will AutoPay based on specific criteria, such as deductibles, coinsurance, copays, eligible fees, etc. If a claim doesn’t meet the eligibility requirements, the claim will not AutoPay. It may need to be filed on a Request for Reimbursement Form, along with proper documentation, or it may be that is not an eligible expense. PLEASE DO NOT FILE CLAIMS THAT WILL NORMALLY AUTOPAY. ONLY FILE CLAIMS MANUALLY THAT DO NOT GO THROUGH YOUR INSURANCE OR MAY NOT PAY THROUGH AUTOPAY AS QUESTIONABLE AS TO ELIGIBILITY FOR FLEX. (Examples include over the counter eligible expenses, etc.) The website available for you to review your claims status and account balance is www.myflexonline.com. For more information regarding FSAs, HRAs, eligible expenses, change in status rules and much more visit Claims processed prior to this authorization will not apply AutoPay and will need to be submitted manually if you choose to have them reimbursed through your FSA or HRA. If you have any other insurance coverage on you, your spouse, or dependents we do not recommend AutoPay. It may create a situation where you are reimbursed for a medical claim from more than one source. The IRS considers this “double dipping” and you may be taxed and penalized if audited. I, authorize FlexShare Benefits to AutoPay certain claims from my Blue Cross Blue Shield of Wyoming insurance to be reimbursed through my Spending Accounts: Medical Flexible Spending Account Health Reimbursement Account Both Accounts Name (please print) Date Signature Social Security Number Employer Name Complete and return this form only if you wish to have certain insurance claims from your employer’s group insurance AutoPay to your flexible spending account. This AutoPay will go into effect one week after returning it to FlexShare Benefits. FLEXSHARE BENEFITS BLUE CROSS BLUE SHIELD OF WYOMING PO BOX 2266 CHEYENNE, WY 82003 1-[PHONE REDACTED] Email @ www.myflexonline.com FlexShare Benefits PO Box 2266 4000 House Avenue Cheyenne, WY 82003 [PHONE REDACTED] 1.[PHONE REDACTED] Fax: [PHONE REDACTED] Email: www.myflexonline.com FSB20 11/07