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Get American Fidelity Reimbursement

Is a New Address? Yes Date of Service No Zip Code Email Address: Description of Expense Family Member for Whom Expense Was Incurred Amount of Expense Medical Dependent Expense Care TOTAL UNREIMBURSED MEDICAL (URM) EXPENSE GUIDELINES: With the expense voucher, you will need to submit a professional bill or receipt that includes the following: 1) Service provider s name; 2) Type of service rendered; 3) Charge for service; and 4) Original date of service. Note: the date of service, NOT th.

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