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Get Mayo Clinic Flex Spending Account Setup Form

Must first file for benefits covered under any other medical, dental, HMO plans or reimbursement accounts.* 2. Complete Section I and II. You will need to attach an original itemized statement and/or receipt for each item you would like reimbursed. If you have received coverage under another plan please submit your Explanation of Benefits (EOB) with your claim form. 3. Submit completed original claim form and original itemized statement/receipt to the address shown at right. SECTION I Last Na.

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