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Microsoft Word - FSA Claim Form - Healthcare JMA (FINAL).doc
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Document Date: 2014-09-03 11:54:53
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File Size: 160,16 KB
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City
Mesa /
/
Currency
USD /
/
/
IndustryTerm
insurance coverage /
insurance payment /
healthcare /
/
Organization
**NAME OF PERSON RECEIVING RELATIONSHIP PROVIDED mm/dd/yy SERVICE /
DATE SERVICE /
Internal Revenue Service /
DESCRIPTION OF SERVICE /
FSA /
Medicare /
/
/
Position
COB /
orthodontist for each periodic reimbursement request /
orthodontist /
/
ProvinceOrState
Oregon /
Arizona /
/
Technology
cellular telephone /
/
SocialTag
Itemized deduction
Income tax in the United States
Reimbursement
Medicare
Government
Business
FSA debit card
Cafeteria plan
Taxation in the United States
Employment compensation