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Employee Signature Date Please return this form to CoreSource Attn FSA/HRA Department P. O. Box 8215 Little Rock AR 72221 Email address coreflex coresource. COREFLEX HealthCare Reimbursemnt Arrangement REQUEST FORM Phone 1-877-267-3359 Fax 1- 501-221-9074 PLEASE NOTE IF ADDRESS IS A NEW ADDRESS A. EMPLOYEE INFORMATION Name Social Security Number Employer Name Address ONLY IF NEW City State Home Phone/Cell Number optional Work Phone Number optional Email Address optional Zip B. HRA ACCOUNT Date of Service Provider of Service Person for Whom Service Provided Relationship to You TOTAL AMOUNT REQUESTED D. CERTIFICATION Amount I certify that the following is true 1. The expenses listed above were incurred by me and/or my eligible dependents and qualify for reimbursement within the current plan year. 3. I have not and will not deduct the above listed expenses on my Federal Income Tax returns. 4. The appropriate Explanation of Benefit Statements from the insurance are attached* Please keep copies of supporting documentation for your records. Documents will not be returned* NOTE Please send an Explanation of Benefits EOB for verification on all requests. COREFLEX HealthCare Reimbursemnt Arrangement REQUEST FORM Phone 1-877-267-3359 Fax 1- 501-221-9074 PLEASE NOTE IF ADDRESS IS A NEW ADDRESS A. EMPLOYEE INFORMATION Name Social Security Number Employer Name Address ONLY IF NEW City State Home Phone/Cell Number optional Work Phone Number optional Email Address optional Zip B. EMPLOYEE INFORMATION Name Social Security Number Employer Name Address ONLY IF NEW City State Home Phone/Cell Number optional Work Phone Number optional Email Address optional Zip B. HRA ACCOUNT Date of Service Provider of Service Person for Whom Service Provided Relationship to You TOTAL AMOUNT REQUESTED D. HRA ACCOUNT Date of Service Provider of Service Person for Whom Service Provided Relationship to You TOTAL AMOUNT REQUESTED D. CERTIFICATION Amount I certify that the following is true 1. The expenses listed above were incurred by me and/or my eligible dependents and qualify for reimbursement within the current plan year. CERTIFICATION Amount I certify that the following is true 1. The expenses listed above were incurred by me and/or my eligible dependents and qualify for reimbursement within the current plan year. 3. I have not and will not deduct the above listed expenses on my Federal Income Tax returns. 4. The appropriate Explanation of Benefit Statements from the insurance are attached* Please keep copies of supporting documentation for your records. 3. I have not and will not deduct the above listed expenses on my Federal Income Tax returns. 4. The appropriate Explanation of Benefit Statements from the insurance are attached* Please keep copies of supporting documentation for your records. Documents will not be returned* NOTE Please send an Explanation of Benefits EOB for verification on all requests. COREFLEX HealthCare Reimbursemnt Arrangement REQUEST FORM Phone 1-877-267-3359 Fax 1- 501-221-9074 PLEASE NOTE IF ADDRESS IS A NEW ADDRESS A. EMPLOYEE INFORMATION Name Social Security Number Employer Name Address ONLY IF NEW City State Home Phone/Cell Number optional Work Phone Number optional Email Address optional Zip B. HRA ACCOUNT Date of Service Provider of Service Person for Whom Service Provided Relationship to You TOTAL AMOUNT REQUESTED D.

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