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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
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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