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Get Hcsa Claim Form Washington

Se this form to request payment from your Medical Reimbursement Account (MRA) and/or Health Care Spending Account (HCSA) Complete Part 1 entirely and legibly. If you do not know your Member ID, refer to your ID card or contact UnitedHealthcare. Complete Part 2 if you are claiming medical, dental, vision, prescription or over-the-counter (OTC) medication expenses (must have a prescription for eligible OTC drugs or medicines; medical supplies do not require a prescription including ).

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