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Participant s signature Date Prodegi PO Box 98 Worland Wyoming 82401 Phone 307-426-5500/800-246-4622 Fax 307-347-6227. The undersigned further understands that no medical expense tax deduction or credit is permitted for amounts for which reimbursement is made. CLAIMANT DATE OF SERVICE SERVICE PROVIDED AMOUNT REIMBURSABLE Total Amount Reimbursable READ CAREFULLY The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of...
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