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Employee s Signat ure Date UNREIMBURSED MEDICAL EXPENSE CLAIMS Date Expense incurred mm/dd/yy Name of Service Provider Expense Description Attach appropriate receipt s and submit with this claim form To complete an electronic claim form or check your account balance go to Copyright 2010 WageWork s TCW W- CFHCA0310 Person for Whom Expense Incurred Total Health Care Expense Claim takecareWageWorks.

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