Flexible Benefit Plan Claim Form - take care plans
PLEASE USE THE FSA OR HRA REIMBURSEMENT CLAIM FORM FOR THOSE EXPENSES. The undersigned participant in the Plan certifies that all services for which reimbursement is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Cafeteria Plan and/or Health Reimbursement Arrangement and that the medical expenses … ................
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