Fillable Co-ordination of Benefits Health Care Spending Account Information ...

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Group Benefits Health Care Expense SECTION 1 - TO BE COMPLETED BY PLAN MEMBER Plan Sponsor Plan Member Address No. Last name Street Plan contract number First name and initial Plan member certificate number Date of birth (yyyy/mm/dd) City Province (yyyy/mm/dd) 1. Is this claim a result of traveling outside the country? No Yes If yes, from to Postal code (yyyy/mm/dd) No Yes 2. Are any of these expenses related to a...
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