Aviben FLEX or HRA Form Submission

Please let us know who is submitting this form

Plan Participant First Name *

Plan Participant Last Name *

Employer Name *

Type of Plan(s) *

HRA

FLEX 125

HSA

Aviben HRA/HSA/FLEX Paperwork Submission Form

Filling out this form does not replace the Aviben Claim Form as we need your signature to approve your claim. Please submit your claim form along with your documentation.

Phone Number *

Email Address * 🛈

Please include any special instructions here

You can either drag and drop your completed transaction documents in the box below, or click "Choose Files" to select the files.
Please only upload PDF files. * 🛈

Yes

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