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Get PayFlex Reimbursement Accounts Claim Form 2012-2024

Ay Care Claims - For additional information, please visit our website at: www.HealthHub.com. Complete this form and have your provider sign below OR attach an itemized statement from your day care provider . Do NOT do both. IRS regulations allow payment of services for dependents under age 13 or otherwise satisfying the “Qualifying Person Test” as described in IRS Publication 503. Payment is only allowed for services that have already been provided, not for services to be provided in the fu.

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