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El free to contact a representative at (877) 311-7849. MAIL CLAIM FORM TO: UnitedHealthcare PO Box 981178 El Paso, TX 79998-1178 Fax: (915) 781-1085 Phone: (877) 311-7849 FLEXIBLE SPENDING ACCOUNT CLAIM FORM Please Read These Instructions Before Completing The FSA Withdrawal Request 1. 2. 3. 4. 5. Employee must complete Part 1. (If applicable, complete Part 2 Health Care Expenses and/or Part 3 Dependent Care Expenses. ) Instructions for Part 2: A. If expenses were covered by any.

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