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Remit To: Plus Point Services 307 oak street hood river, or 97031 PHONE: [PHONE REDACTED] FAX: [PHONE REDACTED] EMAIL: [EMAIL REDACTED] S125 Medical Flexible Spending Account FSA Claim Form PLEASE NOTE: Claims that are not listed on this from cannot be processed. You must complete each field below for each claim you are seeking reimbursement for and attach supporting documentation. S125 FSA CLAIMS – for unreimbursed medical expenses (Attach supporting documentation) Supporting documentation for unreimbursed medical expenses must include all of the following: Provider’s Name Patients Name Service Description Amount Billed Date of Service Date of Service Apply to Plan Year: Current/Previous? Name of care recipient and relationship to employee Name of Medical Provider General Medical Expense Description Amount Total Amount Requested: Employee Confirmation I certify that the claims listed above are a true and accurate statement of all expenses incurred by my eligible dependents or me on the date(s) indicated, and were incurred while I was covered under the S125 Medical Flexible Spending Account. Supporting documentation from my service provider(s) for all expenses is attached to this claim form. I understand that I cannot claim any reimbursed expenses from the plan on my income tax return, and that I may be liable for payment of all related taxes including Federal, State or City income tax and any associated penalties on the amounts paid for any expense improperly claimed under the provisions of the S125 Flexible Spending Account. Employee Signature: Date: Employee Information Employer Name: Daytime Phone: Employee Name: Employee ID: Employee Address: City: State: Zip: Email Address: SIGN