www.goigoe.com
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Submitted URL: http://www.goigoe.com/
Effective URL: https://www.goigoe.com/flex/
Submission: On February 04 via manual from IN — Scanned from DE
Effective URL: https://www.goigoe.com/flex/
Submission: On February 04 via manual from IN — Scanned from DE
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<table style="width: 100%;" height="60px" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td align="left" valign="top" style="height:58px;width:70%;">
<a href="http://www.goigoe.com">
<img alt="" border="0" src="images/main/logo2.png">
</a>
</td>
<td style="height: 60px" valign="top">
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<td class="rcbArrowCell rcbArrowCellRight"><a id="ctl00_Head3_RadComboBox_Forms_Arrow" style="overflow: hidden;display: block;position: relative;outline: none;">select</a></td>
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<div class="rcbSlide" style="z-index:6000;display:none;">
<div id="ctl00_Head3_RadComboBox_Forms_DropDown" class="RadComboBoxDropDown RadComboBoxDropDown_Vista ">
<div id="ctl00_Head3_RadComboBox_Forms_Header" class="rcbHeader">
<a id="ctl00_Head3_RadComboBox_Forms_Header_HyperLink1" class="OrangeLinks" href="WhatForm.aspx" style="display:inline-block;height:100%;width:100%;"><img src="images/icons/Question.gif" align="absmiddle" border="0">
What Form Should I Use?
</a>
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<div class="rcbScroll rcbWidth">
<ul class="rcbList">
<li class="rcbItem rcbTemplate" target="_self">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i0_HyperLink2" class="ComboBoxLink" href="Forms.aspx" target="_self" style="display:inline-block;height:100%;width:100%;"></a>
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<a id="ctl00_Head3_RadComboBox_Forms_i0_HyperLink1" class="ComboBoxLink" href="Forms.aspx" target="_self" style="display:inline-block;height:100%;width:100%;">Download Forms ( Select Form ) ...</a>
</td>
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</tbody>
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</li>
<li class="rcbItem rcbTemplate"
title="Reimbursement Request Form – This Interactive form allows you to request reimbursement for either your medical care spending account, dependent care (daycare) spending account or both (if applicable). Complete this form on your computer then print, sign, scan & upload the form using our secure online utility under your personal login."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i1_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/FSA%20Reimbursement%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i1_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i1_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/FSA%20Reimbursement%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">FSA Reimbursement Request</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="Complete this form to meet the requirements for requesting reimbursement from your dependent day care account. This form also includes an optional provider acknowledgement section that may act as your receipt for expenses incurred should you not have access to sufficient receipt documentation directly from your day care service provider."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i2_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Dependent%20Day%20Care%20Provider%20Acknowledgement.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i2_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i2_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Dependent%20Day%20Care%20Provider%20Acknowledgement.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Dependent Care Reimbursement Request and Provider Receipt</a>
</td>
</tr>
</tbody>
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</li>
<li class="rcbItem rcbTemplate"
title="Use this form to request cashback from your parking or transit account. As a reminder, transit purchases should be made using your Benefit Card. Cashback requests from transit accounts can only be fulfilled if you attest that the Benefit Card was not accepted or available at the time of the purchase."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i3_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Commuter_Cashback_Request_Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i3_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i3_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Commuter_Cashback_Request_Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Commuter Cashback Request Form</a>
</td>
</tr>
</tbody>
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</li>
<li class="rcbItem rcbTemplate" title="HRA Reimbursement Request Form – This form allows you to request reimbursement for eligible health items, outlined in your employers plan documents." target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i4_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/HRA%20Reimbursement%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i4_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i4_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/HRA%20Reimbursement%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">HRA Reimbursement Request Form</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="This form can be used when seeking a post-tax reimbursement for qualified lifestyle expenses. To determine expense eligibility, please review your employer’s Lifestyle Benefits documentation."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i5_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/LifestyleBenefitsReimbursementRequestForm.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i5_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i5_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/LifestyleBenefitsReimbursementRequestForm.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Lifestyle Benefit Reimbursement Request Form</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="The Benefit Card Cover Sheet is intended for the use of Benefit MasterCard holders only. This form is ONLY for items and services that you paid for using your Benefit MasterCard and is only required if you have received an email indicating that additional documentation is needed to determine the eligibility of your expense."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i6_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Flexible%20Benefits%20Card%20Substantiation%20Coversheet.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i6_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i6_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Flexible%20Benefits%20Card%20Substantiation%20Coversheet.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Benefit Card Substantiation Coversheet</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="This form was designed to provide a template for your physician to authenticate the eligibility of your expense. Please note that for expenses to be eligible under the medical FSA, they must be deemed medically necessary. The IRS requires a prescription that meets state requirements if your physician has recommended an over-the-counter (OTC) medicine or drug if you wish to seek reimbursement from your medical care spending account. Use of this form does not satisfy state prescription requirements. If you are in doubt about the eligibility of your expense, ask your provider to complete this form as a precaution."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i7_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Letter%20of%20Medical%20Necessity.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i7_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i7_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Letter%20of%20Medical%20Necessity.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Letter of Medical Necessity Template</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="This form may be completed by your provider to act as notification of the orthodontic treatment duration and cost. All items requested on this form are required for reimbursement. Either a copy of this completed form or a copy of your orthodontia contract indicating all items requested on this form must be submitted with your request for reimbursement to determine eligibility & payment."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i8_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Orthodontia%20Treatment%20Statement.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i8_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i8_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Orthodontia%20Treatment%20Statement.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Orthodontia Treatment Statement</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="Use this form to submit an Explanation of Benefits (EOB) showing that the deductible for your HDHP has been met. This is not a reimbursement request form and will not result in claim remittance."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i9_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/LPFSA%20Conversion%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i9_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i9_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/LPFSA%20Conversion%20Request%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Limited Purpose FSA Conversion Form</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate" title="Use this form if you would like to appeal a claim decision." target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i10_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Claim_Appeal_Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i10_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i10_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Claim_Appeal_Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">Claim Appeal Form</a>
</td>
</tr>
</tbody>
</table>
</li>
<li class="rcbItem rcbTemplate"
title="Due to HIPAA requirements, this form is required each time you would like to have another individual or organization access PHI related to your Flexible Benefit Plan Account or your COBRA continuation."
target="_blank">
<table height="30px">
<tbody>
<tr>
<td width="35px" align="center">
<a id="ctl00_Head3_RadComboBox_Forms_i11_HyperLink2" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Private%20Health%20Information%20(PHI)%20Release%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;"><img id="ctl00_Head3_RadComboBox_Forms_i11_Image1" src="images/icons/docPDF.gif" style="border-width:0px;"></a>
</td>
<td valign="middle">
<a id="ctl00_Head3_RadComboBox_Forms_i11_HyperLink1" class="ComboBoxLink" href="http://www.goigoe.com/Forms/Private%20Health%20Information%20(PHI)%20Release%20Form.pdf" target="_blank" style="display:inline-block;height:100%;width:100%;">HIPAA Release Form</a>
</td>
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<div class="title2" style="font-size:15px; color:#55555; margin-bottom:7px;">INTRODUCING A SMARTER IGOE MOBILE APP</div>
<div class="paragraph">If you have a Spending Account of any type with Igoe, we highly encourage you to download the free Igoe Mobile App available on the App Store or Google Play. Our newly improved Igoe Mobile App allows you to do
the following:</div>
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<li>Submit claims and back up documentation</li>
<li>Manage reimbursement preferences</li>
<li>Use the medicine cabinet to manage prescriptions and find lower cost options</li>
<li>Use a product sku tool to scan a product sku and determine eligibility prior to purchase and more</li>
</ul>
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<div class="paragraph" "="">To register on Igoe Mobile, please follow these <a target=" blank" class="standardLinks" style="font-size:12px;" href="docs/IgoeMobileAppUse.pdf">registration instructions</a> To view common Q/As,
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<div class="OrangeTitleBold" style="margin-left:0px;margin-top:15px; ">Need to replace your Benefit Card?</div>
<div class="paragraph">
<ol>
<li>Log on to your online account</li>
<li>Click on or hover over the "Benefit Card" tab</li>
<li>Select "Benefit Card Management"</li>
<li>Click on the <img style=" vertical-align:middle" src="images/cardloststolen.png"> next to the card you are cancelling</li>
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<div class="OrangeTitleBold" style="margin-left:0px;">Want to order an additional Benefit Card?</div>
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<li>Complete <a class="standardLinks" target="_blank" href="https://www.goigoe.com/Forms/Additional_Card_Holder_Request.pdf">this form</a> and email it to
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<div class="OrangeTitleBold" style="margin-top:5px">Need an RX?</div>
<div class="paragraph">If you want to submit a claim or substantiate a benefit card purchase for an item that requires a Letter of Medical Necessity or an RX, we’ve created
<a target="_blank" class="standardLinks" href="https://www.goigoe.com/Forms/Letter%20of%20Medical%20Necessity.pdf">this form</a> that you can have your service provider complete.</div>
<br>
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<div class="OrangeTitleBold">Receiving Plan Communications?</div>
<div class="paragraph">Are you receiving communications from Igoe? Take a moment to review your communication preferences on your online account. You can sign up for a variety of email and text alerts ranging from
monthly balance updates to plan year end spending and submittal deadline reminders. It’s also a good idea to add Igoe Administrative Services as a safe sender by approving the following two email addresses to your
safe sender list: <a class="standardLinks" href="mailto:bcs@goigoe.com">bcs@goigoe.com</a> and <a class="standardLinks" href="mailto:flex@goigoe.com">flex@goigoe.com</a>. </div>
<div class="OrangeTitleBold">Want to Allow Account Access to Another Person?</div>
<div class="paragraph">Your privacy is important to us (plus we have to abide by HIPAA). As a result, you will need to complete and submit this
<a href="https://www.goigoe.com/Forms/Private%20Health%20Information%20(PHI)%20Release%20Form.pdf" class="standardLinks" target="_blank">release form</a> if you wish to have someone else access your account
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</form>Text Content
select
What Form Should I Use?
* Download Forms ( Select Form ) ...
* FSA Reimbursement Request
* Dependent Care Reimbursement Request and Provider Receipt
* Commuter Cashback Request Form
* HRA Reimbursement Request Form
* Lifestyle Benefit Reimbursement Request Form
* Benefit Card Substantiation Coversheet
* Letter of Medical Necessity Template
* Orthodontia Treatment Statement
* Limited Purpose FSA Conversion Form
* Claim Appeal Form
* HIPAA Release Form
Participants
Employers
Brokers
Contact Us
About Us
* Spending Accounts
* Spending Account Resources
* Plan Limits and Mileage Rates
* COBRA Resources
* COBRA Login
* COBRA Frequently Asked Questions
* Department of Labor's Site
* Know Your Health Benefits Rights
* Get Forms
* Download Forms
* What Form Should I Use
* Submitting FSA Reimbursement Forms
* Common Request Mistakes
Home > My Spending Accounts Sign In
Spending Account Portal
SIGN IN
Registration Help?
INTRODUCING A SMARTER IGOE MOBILE APP
If you have a Spending Account of any type with Igoe, we highly encourage you to
download the free Igoe Mobile App available on the App Store or Google Play. Our
newly improved Igoe Mobile App allows you to do the following:
* Submit claims and back up documentation
* Manage reimbursement preferences
* Use the medicine cabinet to manage prescriptions and find lower cost options
* Use a product sku tool to scan a product sku and determine eligibility prior
to purchase and more
To register on Igoe Mobile, please follow these registration instructions To
view common Q/As, click here
Resources
Videos, FAQs and More
Forms
Eligible Product List
Dependent Care Expense List
FSA Store
HSA Welcome Kit
Plan Limits and Mileage Rates
COBRA Member Login
Need Help? Here are guides for our top FAQs
How to Submit Claims
How to Register on the Igoe
Participant Portal
How to Register for Igoe Mobile
How to Set Up Direct Deposit
How to Order a Dependent
Benefit Card
Need to replace your Benefit Card?
1. Log on to your online account
2. Click on or hover over the "Benefit Card" tab
3. Select "Benefit Card Management"
4. Click on the next to the card you are cancelling
5. Request a new card in the replacement card window at the bottom of the
screen. TIP: You may need to scroll down to see the replacement card window.
Want to order an additional Benefit Card?
1. Complete this form and email it to flex@goigoe.com
Need an RX?
If you want to submit a claim or substantiate a benefit card purchase for an
item that requires a Letter of Medical Necessity or an RX, we’ve created this
form that you can have your service provider complete.
Receiving Plan Communications?
Are you receiving communications from Igoe? Take a moment to review your
communication preferences on your online account. You can sign up for a variety
of email and text alerts ranging from monthly balance updates to plan year end
spending and submittal deadline reminders. It’s also a good idea to add Igoe
Administrative Services as a safe sender by approving the following two email
addresses to your safe sender list: bcs@goigoe.com and flex@goigoe.com.
Want to Allow Account Access to Another Person?
Your privacy is important to us (plus we have to abide by HIPAA). As a result,
you will need to complete and submit this release form if you wish to have
someone else access your account information with an Igoe Participant Services
Representative.
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