BASIC Flex Administrative Forms

BASIC Flex Renewal Wizard

BASIC Flex spreadsheet
See instructions below on how to safely access and send your BASIC Flex initial group set up, renewal and mid year enrollments.

To Download File: Right-click on link, than Select ‘Save Target As’, type your company name for the file name and save on your computer or network.Enrollment spreadsheet
Security: Upload your completed spreadsheet using our Secure File Submission found at this link,

BASIC Flex participation information change form
Use this form if an employee has a status change such as an increase in election, change in per pay, termination of coverage or address change.
Online form

BASIC Flex document change form
Use this form to make any changes to your plan including benefit coordinator change, plan year change or coverage change.
Download PDF

BASIC Flex reimbursement forms
Reimbursement forms

BASIC Flex direct deposit form
Click the link below to open the form used to request direct deposit for you BASIC Flex reimbursements.
Fillable PDF

BASIC Flex debit card refund form
Participants use this form when they need to refund their employer due to an ineligible debit card charge.
Fillable PDF

BASIC Flex enrollment booklet
Click the link below to open the 8 page BASIC Flex enrollment booklet.
Download PDF

BASIC Flex enrollment form
Click the link below to open the enrollment form for BASIC Flex. Do not use this form if you want to sign up for BASIC Flex Limited Purpose or if you have a Health Savings Account (HSA).
Fillable PDF

BASIC Flex Self Administration enrollment booklet

This enrollment booklet is only used when an employer acts as the Flex administrator. Do not use this booklet if BASIC handles your plan administration.
Download PDF

Letter of Medical Necessity
This form needs to be submitted, or a provider’s letter containing the same information, with each claim that is submitted for the service or product requested.
BASIC Flex – Letter of Medical Necessity Form

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