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And I understand that funds I repay the Plan for ineligible expense may be used for reimbursement to me for eligible expenses incurred during the applicable Plan Year. EMPLOYEE SIGNATURE MEDCOM CUSTOMER SERVICE 800. 523. 7542 or 904. 596. 4500 If you have questions refer to the Plan Document and Summary Plan Description for complete details regarding your benefits Munroe FSA CLAIM FORM ed 0669 ed 0669. FLEX CLAIM FORM MAIL TO FAX TO MEDCOM FLEX DEPT P. O. BOX 10269 JACKSONVILLE FL 32247-0269 904. 421. 3696 EMPLOYEE NAME Print SOCIAL SECURITY NUMBER FORMER NAME IF CHANGED NEW ADDRESS IF CHANGED FLEXIBLE BENEFIT PLAN Street City State Zip YOUR CLAIM CAN NOT BE PROCESSED IF THE FOLLOWING SUBSTANTIATION IS NOT ATTACHED Medical Claims Insurance Explanation of Benefits EOB Medical Provider invoice containing diagnosis Prescription for treatment etc. Dependent Day Care Claims Invoices itemized by Payment Frequency and with the name of the Day Care Provider TaxID Number dates of service and the name of person receiving the service. Please reimburse me for Medical Expenses Totaling DCAP CLAIMS WILL NOT BE CONSIDERED FOR PAYMENT UNLESS THE TWO QUESTIONS BELOW ARE ANSWERED Payment Frequency of DCAP expenses Daily Monthly Weekly Other Describe DAY CARE Child Spouse EXPENSES INCURRED BY NAME Self Check Date of Birth Did you work all days during the DCAP claim period Yes if NO please enter total number business days not worked Total number days not worked days ITEMIZE TOTAL EXPENSES PROVIDER OF SERVICE Include Tax ID if for Day Care INCURRED DATE FSA DCAP TOTAL SUBMITED I hereby certify that the above requested reimbursement is for eligible services received by either myself or eligible tax dependents if any. FLEX CLAIM FORM MAIL TO FAX TO MEDCOM FLEX DEPT P. O. BOX 10269 JACKSONVILLE FL 32247-0269 904. 421. 3696 EMPLOYEE NAME Print SOCIAL SECURITY NUMBER FORMER NAME IF CHANGED NEW ADDRESS IF CHANGED FLEXIBLE BENEFIT PLAN Street City State Zip YOUR CLAIM CAN NOT BE PROCESSED IF THE FOLLOWING SUBSTANTIATION IS NOT ATTACHED Medical Claims Insurance Explanation of Benefits EOB Medical Provider invoice containing diagnosis Prescription for treatment etc* Dependent Day Care Claims Invoices itemized by Payment Frequency and with the name of the Day Care Provider TaxID Number dates of service and the name of person receiving the service. Please reimburse me for Medical Expenses Totaling DCAP CLAIMS WILL NOT BE CONSIDERED FOR PAYMENT UNLESS THE TWO QUESTIONS BELOW ARE ANSWERED Payment Frequency of DCAP expenses Daily Monthly Weekly Other Describe DAY CARE Child Spouse EXPENSES INCURRED BY NAME Self Check Date of Birth Did you work all days during the DCAP claim period Yes if NO please enter total number business days not worked Total number days not worked days ITEMIZE TOTAL EXPENSES PROVIDER OF SERVICE Include Tax ID if for Day Care INCURRED DATE FSA DCAP TOTAL SUBMITED I hereby certify that the above requested reimbursement is for eligible services received by either myself or eligible tax dependents if any.

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