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Get Health Care Spending Account Reimbursement ... - Sunyit

IP CODE SECTION B SUMMARY OF HEALTH CARE SPENDING ACCOUNT EXPENSES NAME OF PERSON RECEIVING SERVICES RELATIONSHIP TO ENROLEE DATES SERVICE PROVIDED FROM MO/DAY/YR NAME AND ADDRESS OF PROVIDER OF SERVICES (ex.: hospital, doctor, dentist, pharmacy, medical supply store) TO MO/DAY/YR AMOUNT TO BE REIMBURSED $0.00 TOTAL AMOUNT $ I understand, agree and certify to the following: I will use my HCSAccount only to pay for IRS-qualified expenses, permitted under the HCSAccount p.

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