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Get North Carolina Ameriflex Claim Form

Nse Incurred Receiving Medical Service Service Provided Provider Name (Physician, Hospital, Dentist, Pharmacy, etc) (Co-Pay, Deductible, Dental, Vision, RX, over-the-counter, etc) Amount Requested Dependent Day Care Claims Dependent Name Dependent DOB Date of Service From To Provider Name Provider Tax ID # Type of Service (Day Care, Pre-K, Day Camp, etc) Amount Requested Provider Signature or Stamp (if no receipt is available) Commuter/Transportation Expense Claims Expense Type Park.

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