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ORIGINAL SUBMISSION RESUBMISSION Health Care Reimbursement Account Request A. INSTRUCTIONS Complete sections B C and D If expense is covered by insurance submit to appropriate carrier Attach explanation of benefits EOB from the insurance carrier or co-pay receipts Itemized bills should include the following 1 Provider name and address 2 Patient name 3 Itemized charges 4 Date of service 5 Type of service Cancelled checks non-itemized receipts and.

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