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By reimbursements I mean any money received for any members of your CU from an insurance company, medical care provider or non-CU member for medical expenses which you previously paid or will pay. Do not include reimbursements from a flexible spending account.
Since the first of the reference month, have you or any members of your CU received any medical reimbursements?
* IF YES - What did you get reimbursed for?
Describe the care/service/item. [enter text] _____________
Who was/were the "care/service/item" for?
* Enter name of person: [enter text] _____________
In what month was(were) the reimbursement(s) received? [enter text] _____________
What was the total amount received? [enter value] _____________
* Enter 'C' for a combined reimbursement
What other medical reimbursement is the "care/service/item" combined with?
* Enter all that apply
Did you or any members of your CU receive any other reimbursements for the "care/service/item"?
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Last Modified Date: November 21, 2006