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Get Po Box 785040

Y OUR S PENDING A CCOUNT P. O. Box 785040 Orlando FL 32878-5040 Fax 1-888-211-9900 Health Care/Dependent Care Claim Form Name Last/First/MI Social Security Number Address City Daytime Telephone Number State Zip Code Employer HEALTH CARE CLAIMS Date of Service mm-dd-ccyy Provider Type of Service Patient Requested Amount Health Care Total Prescription Over-the-Counter OTC Drugs Medical Dental Vision Hearing DEPENDENT CARE CLAIMS Service Provider De....

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