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Title:FSA/HRA Reimbursement Claim Form 200-8
Summary:pdf file (Rev. 10/07)
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Handle: Document-26888
Owner: Goodman, Tina (User-6429, tgoodman:DocuShare)DS
Create Date:Tuesday, November 20, 2007 08:49:43 AM EST
Modified Date:Tuesday, November 20, 2007 08:49:43 AM EST
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Abstract:
  • FSA/HRA REIMBURSEMENT CLAIM FORM (Please Print Clearly) PART 1 PART 2 Check here if address has changed and provide new information below.
  • Medical expenses were incurred only for an immediate medical purpose.
  • 2.
  • Part 2 of the claim form should only be completed if your address has changed.
  • • The service being claimed must be provided within your Plan Year to you, your spouse or your dependent.
  • within the timeframes specified in the Plan Highlights. • The expense being claimed cannot be reimbursed from any other source.
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Content Type: Adobe Portable Document Format (.pdf) - application/pdf
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File name:FSAClaim2007[1].pdf
Hlth,PE & Home Ec:
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Max Versions:4
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Size:109092
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Ready for Declare:No
Appears In: Payroll Dept.
Preferred Version: FSA/HRA Reimbursement Claim Form 200-8