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Employee Signature Date Please return this form to CoreSource Attn FSA/HRA Department P. O. Box 8215 Little Rock AR 72221 Email address coreflex coresource. COREFLEX HealthCare Reimbursemnt Arrangement REQUEST FORM Phone 1-877-267-3359 Fax 1- 501-221-9074 PLEASE NOTE IF ADDRESS IS A NEW ADDRESS A. EMPLOYEE INFORMATION Name Social Security Number Employer Name Address ONLY IF NEW City State Home Phone/Cell Number optional Work Phone Number optional Email Address optional Zip B. HRA ACCOUNT...
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