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Get Flexible Spending Account: Authorization For Release ... - Nc.gov

Authorized to receive information Relationship Please indicate the information to be used or disclosed. All information including claim and provider detail Account balance information and reimbursement amounts only Information restricted to only: Duration Please indicate the requested length of this authorization. This authorization is a one-time disclosure and will expire T his authorization is continuous and on going until BMO receives written notice of cancellation or if earlier, one year.

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