• Elevance Health West Virginia Flex Fund Request Form

  • Elevance Staff Requestor Information


  • Please enter a corporate email address from an approved email domain.

  • Member Information

  •  - -
    Pick a Date
  • Payment Request Details

  • Public Transportation

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Technology Needs

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Vehicle Maintenance/Repair

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Clothing/Professional Appearance

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Barriers to Accessing Employment, Education & Training

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Housing Flex Fund

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Other

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Additional Expense(s)

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Additional Expense Approval

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Clear
  •  / /
    Pick a Date
  • Should be Empty: