 |
| Title: | FSA/HRA Reimbursement Claim Form 200-8 |
| Summary: | pdf file (Rev. 10/07) |
| Description: | |
| Keywords: | |
| Handle: |
Document-26888
|
| Owner: |
Goodman, Tina (User-6429, tgoodman)
|
| Create Date: | Tuesday, November 20, 2007 08:49:43 AM EST |
| Modified Date: | Tuesday, November 20, 2007 08:49:43 AM EST |
| Modified By: |
|
| Expiration Date: | |
| Locked By: |
|
| Abstract: | - Date( s) of Service Amount For Office Use OnlyYESYESYESYESYESYESYESYESYESYESYESYESYES TOTAL Employee Certification: I request reimbursement for Medical and/ or Dependent Care expenses as indicated above.
- Name of provider Your out- of- pocket cost for the service Date( s) service was provided Name of person receiving the service Type of service provided (for prescriptions, must include name of drug) IRS regulations may require additional documentation for certain expenses (e.
- Submit the completed claim form and related documentation to: ATTN: Claims DepartmentBenefit Resource, Inc.2320 Brighton- Henrietta TL Rd.Rochester, NY 14623- 2782 Fax: (585) 427- 9320 CLAIM SUBMISSION REMINDERS: Credit card statements, cancelled checks and ...
|
| ARTS: | |
| Author: | |
| CDOS: | |
| Content Type: | application/pdf |
| ELA: | |
| File name: | FSAClaim2007[1].pdf |
| Hlth,PE & Home Ec: | |
| Level: | |
| LOTE: | |
| Max Versions: | 4 |
| MST: | |
| Other Connection: | |
| Size: | 109092 |
| SS: | |
| Appears In: |
Payroll Dept.
|
|
|
