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FSA CLAIM FORM SECTION I. EMPLOYEE INFORMATION Full Name As It Appears on your FSA Debit Card Social Security No. Name of Employer Street Address City State Zip Daytime Phone No. HEALTH CARE EXPENSES
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The visio-substantiation form flex id is a document used to verify and support claims regarding flexible spending account expenses.
Employees who have utilized their flexible spending account funds and need to provide proof of eligible expenses.
The form typically requires the individual to provide details of the expense, including date, amount, and a description of the service or item purchased. Receipts or invoices may also need to be submitted as supporting documentation.
The purpose of the form is to ensure that funds from flexible spending accounts are being used for eligible medical expenses and comply with IRS regulations.
Information such as the date of the expense, the amount spent, the type of service or item purchased, and any relevant receipts or invoices.
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