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Form Title: WageWorks Health Care Flexible Spending Account Claim Form
Last Revised: 1/2009
Purpose: Allows reimbursements from the WageWorks Health Care Flexible Spending Account. Plan effective 1/1/09.
Who Should Use the Form: Employees contributing to Health Care Flexible Spending

Employee completes the form and signs.  Mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512, OR fax toll-free to: 1-877-353-9236 (no cover page is required)

View/Fill Out the Form: Click here to view and/or use the form in .pdf format
Problems? Contact: Irena Haimsky, x8706

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