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I want all my eligible expenses paid directly from my HCSA. Description of Expense Date of Expense Dependent Name Amount Total Amount Claimed By signing this claim form and/or submitting original receipts I agree that the information provided is complete and accurate to the best of my knowledge. HEALTH CARE SPENDING ACCOUNT CLAIM SUBMISSION FORM Green Shield I. D. Alternate I. D. Date of Birth // YY Surname MM DD First Name Mailing Address Teleph.

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