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Get Health Reimbursement Arrangement Claim Form - Savers ...

(Please print.) Employer: (Please print.) Last 4 digits of Social Security No.: XXX XX The undersigned Participant in the Plan requests reimbursement in the amounts shown below. Federal law stipulates that written statements (such as itemized receipts, bills, or invoices from the service provider) must accompany all claims, as well as proof that the claim is not being reimbursed by in.

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