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Mber Plan Year Health Care Expenses Accounts: FSA = Flexible Spending Account, HRA = Health Reimbursement Arrangement, OIP = Outside Insurance Premium Account, PKG = Qualified Parking Account, TRN = Qualified Transportation Account Date of Service Account Type of Service Patient TOTAL CLAIMS: Dependent Care Expenses Date of Service From: To: Amount Dependent Name Amount TOTAL CLAIMS: Daycare Provider Information: Name: _____________________________________________ Provider Signature:.

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