UNREIMBURSED MEDICAL CARE EXPENSE CLAIM FORM

FLEXIBLE SPENDING ARRANGEMENT
(FUNDED WITH YOUR SALARY REDIRECTIONS)

Please select one of the options below:

I do not have a Benefits Debit MasterCard®

| Flex Plan Participants | HRAs | FSAs | COBRA | About Admin America | HIPAA Privacy Notice |

Admin America, Alpharetta, GA
Phone: (770) 992-5959 or (800) 366-2961  e-mail: info@adminamerica.com