PLAN YEAR. PLEASE PRINT. MyFlexOnline (Set up Instructions) MyFlexOnline (Reset User Name & Password Instructions) MyFlexOnline (Requesting Additional Flex Card Instructions) MyFlexOnline (Substantiating Debit Card Charge Instructions) MyFlexOnline (How to Pay a Balance Due) DID YOU KNOW? CPN HAS PARTNERED WITH FSA STORE. ConFlex XL High Build Coating is an elastomericlindsay@cpnflex. 2WWW. F. CPNFLEX. COM) Read Carefully: When filing your claim, you must attach copies of the receipts. If you wish to change your Primary Contact in the future, you must complete an Employer Change Form, which can be requested by calling Business Relations at 866 -357 [email protected]. Do you have CPNFLEX app problems? We have instructions to fix the not working issue, loading problems or the common black screen / white screen issue etc. New Indexed PCORI Fees Issued – Update 11/22/2016 Under the Affordable Care Act, (ACA) a fund for a new nonprofit corporation to assist in clinical effectiveness research was created. 0125 Annual Debit Card Fee Invoice: [email protected]. Enter your usernameConFlex XL™ High Build Acrylic Coating is a water proofing coating designed for masonry and concrete surfaces. PLAN YEAR. 1-800-737-0125 / 901-756-8244 / 901-756-8322 Fax / claims@cpnflex. ConFlex XL™ High Build Acrylic Coating is a water proofing coating designed for masonry and concrete surfaces. com CPN's Customer Care Center can be reached Monday-Friday, 8:00 a. KGS. Find their phone numbers & email addresses. Dependent care regulations . First time logging in? Create an account. A. The last update of the app was on July 13, 2023. The receipt must include the service provider’s name and the date and type of service for each expense. Is the Invoicing Contact the same as the Primary Contact? Yes No * If your Primary Contact and Invoicing Contact are not the same, please provide the Invoicing Contact’s information below. Employee COBRA Notice & Election Form . Plan Design Comparisons Use the below chart to compare plan design and compliance issues between Health Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRAs), and Health Savings Accounts (HSAs). Since 1984, CPN has been committed to providing superior administration services for a very diverse group of clients nationally. CPNFLEX. ConFlex SherLastic is. *If your plan is ran on a Non-Calendar year, these examples will alter based on the plan year schedule. Nov. 844. Canceled checks, credit card slips, or statements of balance due are not acceptable. ConFlex Flexible Concrete Waterproofer provides a slip-resistent, breathable finish designed to protect concrete surfaces from water intrusion. Title: Microsoft Word - FORM_Tran_Roll_HSA_081711. Founded Date 1984. Both types will seal your exterior walls and both have the ability to allow excess water out of your walls. tions/P15B/2016/A/XML/Cycle08/source 11:41 - 23-Dec-2015 The type and rule above prints on all proofs including departmental reproduction. For Health Care Professionals: CignaForHCP. com GENDER Unspecified USERNAME For help, contact Customer Service at (901) 756-8244, toll free (800) 737-0125 or claims@cpnflex. The next page will take you to the below screen. REDUCE CALLBACKS WITH CONFLEX XL. Regulations for Dependent Care Expenses . Get everything you need to run your project-centric business in one solution—Microsoft Dynamics 365 Project Operations. com E-mail: Title: Flexible Benefit Plan Claim Form Author: Patricia S. Passbook will be available after 6 Hours of registration at Unified Member Portal. Page 2 of 27 Fileid:. comCPNFLEX is on the top of the list of Medical category apps on Google Playstore. 1 It’s a great way to potentially grow HSA funds for healthcare expenses, or save funds as a. If you did not use your CPNFLEX card and need reimbursed for a qualified expense you paid out-of-pocket, you may submit a claim to CPN for reimbursement. Compliance Alert: Stand-Alone HRAs for Small. [email protected] @cpnflex. For information, contact Alan Lane or e-mail . to 4:30 p. com Method of payment: Employer will send via ACH to CPN Employer accepts CPN to pull funds (appropriate document to be completed) Acceptance of contributions : Employer will send monthly Employer will send quarterly Employer will send on 15 th & EOM3 C. 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and asConFlex™ UltraCrete™ is the efficient, economical one-coat solution to enhancing properties and reducing maintenance. In addition to enterprise quality phone features, PennFlex Phone offers enhanced unified communications functionality including a mobile and desktop app with messaging and audio/video conferencing. Toggle navigationWe propose to develop systems and control theory needed to understand and control large flexible structures and fluid structure interactions. Only those expenses that are not otherwise covered by insurance (e. What is a Health Savings Account (HSA)? An HSA is a tax favored account used in conjunction with an HSA-compatible health plan. All rights reserved. Our secure app makes managing your health benefits easy through real-time access and intuitive navigation to all your important account information on the go! New user registration and login page for registered users. 00 $300. alan@cpnflex. Method of payment: Employer will send via ACH to CPN Employer accepts CPN to pull funds (appropriate document to be completed) Acceptance of contributions : Employer will send monthly Employer will send quarterly Employer will send on 15 th & EOMSherwin-Williams Company 101 Prospect Avenue Cleveland, OH 44115 Tel: (800) 321-8194 Fax: (216) 566-1392. COM) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health Reimbursement Arrangement (HRA) with respect to such. CoinFLEX is the Home of Crypto Yield and is committed to providing institutions and retail investors an easily accessible platform to earn and trade crypto. CPNFLEX. m. Nov. A. Effective/Updated as of 9/01/2020. OLICY. It has an enhanced filling qualities that allows for application over spalled and deteriorated concrete surfaces. This is Sherwin-Williams. DEPENDENT SETUP REQUEST . com E-mail: Title: Flexible Benefit Plan Claim Form Author: Patricia S. Log into the Penn Foster Student Area now. C. Q: I have misplaced my user name and password for the employer EFlexOnline account. provided in Notice 2013-54, 2013-40 IRB 287; FAQs about Affordable Care Act Implementation (Part XXII) issued by the Department of Labor on November 6, 2014;Page 2 of 31 Fileid:. com E-mail . The Institute is responsible for setting national research priorities and establishing an agenda to carry out theCPNFLEX is Free Medical app, developed by Corporate Planning Network. Note: This form is also used for adding Dependents for the Dependent Care Spending Account. Toll Free: 800. Message and data rates may apply. Tools Checker. DEPENDENT SETUP REQUEST . COM) Read Carefully: When filing your claim, you must attach copies of the receipts. com . CPN, INC. 8244 x102 Toll Free: 800. COM) Read Carefully: When filing your claim, you must attach copies of the receipts. It helps global enterprises organize, automate, and optimize their processes on-premises, in the cloud, or through hybrid deployment. are no provisions for late entry into the national phase in India. Powered by WEX Health © WEX Health Inc. and . For Employers and Plan Sponsors: Cigna for Employers . The Institute is responsible for setting national research priorities and establishing an agenda to carry out theWWW. Take a picture of your Itemized Statement/EOB. After you swiped your card, go to CPN’s website . Broker/ Consultant. Section 125 Cafeteria Plan (Health FSA & Dependent Care) Complete this form when a change in status has occurred which affects your Cafeteria Plan election. New Indexed PCORI Fees Issued – Update 10/31/2017. rep gethuman grp login page free cpn number Aug 25 2022 web cpns as a form separating from taxes free instant shipping scn number or cpn numbers are legal receive the kindle version absolutely free via kindle matchbook insteadPage 2 of 20 Fileid:. 1. 1. com Phone: 901. Thus, here the configuration is a tree structure with two types of nodes: Section and Option. com . 756. ENROLLMENT FORM FOR THE CPNFLEX BENEFITS PLAN . 30 Days Free Trial. A Health Savings Account (HSA) is an individually owned, tax‐advantaged account that you can use to pay for current or future IRS‐qualified medical expenses. (For use by single-employer group health plans) [Enter date of notice] Dear: [Identify the qualified beneficiary(ies), by name or status] This notice contains important information about your right to continue your health care coverage in the [enter name of plan] (the HRA). Wells Created Date:October 10, 2017 . 756. Section 125 Cafeteria Plan (Health FSA & Dependent Care) Complete this form when a change in status has occurred which affects your Cafeteria Plan election. COM) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health Reimbursement Arrangement (HRA) with respect to such. 8244 x102. OPTION 1A – HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA) Your employer sets the annual maximum contribution amount for the FSA. 5. UTC: Monday, 13 November at 19:00 – Tuesday, 14 November at 7:00. . Email: katherine@cpnflex. 3 C. F. This facility is to view the Member Passbook for the members registered on the Unified Member Portal. Se require toda la información o su insripción no se puede procesar. OPTION 4 – PARKING ACCOUNTSalesforce Customer Secure Login Page. Catalog ID: 175396101736. COM) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health ReimbursementPlan Design Comparisons Use the below chart to compare plan design and compliance issues between Health Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRAs), and Health Savings Accounts (HSAs). com. Click on 3. FLEX RISER, 1 1/4IN MPT X 1 1/4IN IPS SDR-10, PE COMP X 36" LONG. Switch to a Comprehensive. 2. The Home Page is easy to navigate: • Easily access the Available Balance and “I Want To” sections from the left-hand navigation area. PO Box 1748 · Cordova, TN 38088 . Cards can only be issued for those 18 years, or older. The Primary Contact is the only individual who will have full administrative rights. Click on Add Dependent. © WEX Health Inc. doc Author: aewald Created Date: 8/17/2011 1:19:51 PMCorporate Planning Network. WWW. Catalog ID: 155396101536. Click on. Commercial strength block filler that lays down a great foundation for most masonry block surfaces, interior and exterior. 1. m. This will direct you to… 4. for current year maximums. Make payments, access invoices, view past orders and more. 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and as10. tions/P502/2015/A/XML/Cycle05/source 9:04 - 11-Jan-2016 The type and rule above prints on all proofs including departmental reproduction. awsdns-27. 5. PT: Monday, November 13 at 3:30 pm – Tuesday, November 14 at. orFlex Benefits Card . $735. Mail to: CORPORATE PLANNING NETWORK, INC. PROFILE > Click on Login Information. Simplified renewal process. netPage 2 of 5 CPN. 737. Page . The Affordable Care Act (ACA) created the Patient-Centered Outcomes Research Institute (PCORI). Once you take a picture , you have the option to Use the current photo or to Retake. 2. 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and asChange in Status/Termination Election Form . . Click Login. 6. 737. 20. Author: Rose Heineman Created Date: 12/30/2013 12:02:01 PM. m. Value (INR) Per Unit (INR) Nov 17 2016. awsdns-03. 5. com. 2 ½ Month Extension . Only one (1) card can be added at initial setup. 3 C. Regulations for Dependent Care Expenses . INSURANCE CO-PAYS: Medical Office Visit Co-Pays: _____ Emergency Room Co. Small contributions to your HSA can really help you build a financial safetyHSA BANK Quick Guide: Portal Enrollment File Upload 3 © 2020 HSA Bank. Whether it’s increased premiums, co-pays, deductibles you may be required to pay before your insurance begins to pay your The Loxon XP is manufactured by Sherwin Williams and elastomeric is a type of coating manufactured by many companies. 52. The Primary Contact is the only individual who will have full administrative rights. This app had been rated by 1 users. Find out how to log in, manage your account, and get support from the Salesforce team. 89. tions/P502/2015/A/XML/Cycle05/source 9:04 - 11-Jan-2016 The type and rule above prints on all proofs including departmental reproduction. After you swiped your card, go to CPN’s website . Please enter your 5 digit zip code. 15 ConFlex® Flexible Concrete Waterproofer-Textured CF15W0051 Extra White, CF15W0053 Deep Base CHARACTERISTICS ConFlex™ Flexible Concrete Waterproofer Textured is an interior-exterior flexible and breathable waterproof coating based on aWWW. OPTION 1A – HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA) Your employer sets the annual maximum contribution amount for the FSA. Save time and hassles while making the most of your HRA and FSA health benefit accounts by quickly checking your balances and details. Must money be deposited in my account before I file a claim? NO. 3. Canceled checks, credit card slips, or statements of balance due are not acceptable. 2. A wellness program that provides a tee-shirt to every participant would be considered a de minimis fringe benefit and excludableHealth Savings Account (HSA) Employer Enrollment Form Mail or fax completed forms to: Address: HealthEquity, Att n: Client Services 15 W Scenic Pointe Dr, Ste 400, Draper, UT 84020Email: [email protected] . 1) release to Sandbox environments at the following times during the release window: AEDT: Tuesday, 14 November at 10:30 am – 10:30 pm. 6. 2. We deeply appreciate having you as part of our community and look forward to the opportunities and adventures that the future holds. Employer _____ Social Security Number _____CONFLEX Block Filler. 62, DNS Server: ns-1240. Email address (this is used for monthly email notifications; generated only if you have HSA. ConFlex Risers conform to trench depth and flex with ground movement. HSA Bank is a division of Webster Bank, N. m. PCORI Fees Due by July 31, 2021 . CPN, Inc. It’s part of the Microsoft Dynamics suite of intelligent business applications. Dependent care regulations . PO Box 1748, Cordova, Tennessee, 38088, United States (901) 756-8244. com E-mail: Title: Flexible Benefit Plan Claim Form Author: Patricia S. › Cpnflex login › Cpnflex. From your main Benefits screen, place your curser over Claims & Payments and select View Claim Activity1. Log onto your Consumer Portal account. claims@cpnflex. The funds in the account areSave time and hassles while making the most of your HRA and FSA health benefit accounts by quickly checking your balances and details. Katherine Reder has been working as a Director, Administration & Debit Card Services at CPN for 18 years. SSN *. Title: Flexible Spending Account (FSA) Tax-Free Transportation/Parking Reimbursement Claim Form Author: Katherine Reder Created Date:Page 2 of 27 Fileid:. Web welcome to edgenuity, this is the login portal for all student and educator accounts. uk, ns-30. Currently, CPNFLEX for Windows has got over 100+ App installations and 0 star average user aggregate rating points. Our secure app makes managing your health benefits easy through real-time access and intuitive navigation to all your important account information on the go! Powerful features of the app include: Easy, Convenient & Secure •. Our secure app makes managing your health benefits easy through real-time access and intuitive navigation to all your important account information on the go! Power…GOC_EV1_Form_Proposal_10052022 Group Online Contribution (GOC) Form Please complete and sign this form and the corresponding agreement for group online contributions. • Simply login to the intuitive app using your same health benefits website username and password (or follow alternative instructions if provided) • No sensitive account information is ever stored on your mobile device. User name b. • Simply login to the intuitive app using your same health benefits website username and password (or follow alternative. What if an employee had an FSA for the Previous Plan year, and takes out an HSA in the Current Plan year? A: If an employee had an FSA for their Previous plan year, and takes out an HSA for their nextFuture Developments What's New - cpnflex. Compliance Alert: Who is a Dependent – Update 8/15/2017. awsdns-05. 3. Or you may contact CPN via email: claims@cpnflex. 1. - 4:00 p. CONFLEX Corporation provides conformation search and analysis software for examining the conformational space of small and large molecules. ConFlex™ Acrylic Coating delivers easy application and consistent performance. R. com . NQE Amount . The Institute is responsible for setting national research priorities and establishing an agenda to carry out theConflux Network: Building a multi-chain ecosystem to enable creators, communities, and markets to connect globally across borders and protocols. Se require toda la información o su insripción no se puede procesar. 3. If the photo looks good, select Use to continue. . Powered by WEX Health Save time and hassles with CPNFLEX! Save time and hassles while making the most of your HRA and FSA health benefit accounts by quickly checking your balances and details. For Medicare Customers: CignaMedicare. 2 ½ Month Extension is when a company offers for two months and fifteen days after a plan year ends, any remaining FSA funds left on a prior FSA plan year, to pay first. 2. 116. F. F. During FY21 and FY22, PennFlex. Plan Administrative Services and Benefit Services are administered by Webster Servicing LLC. 1. CPN's Customer Care Center can be reached Monday-Friday, 8:00 a. When primed with Loxon® Concrete & Masonry Primer/ Sealer, this system achieves a durable finish that resists challenging weather conditions like winddriven rain while inhibiting the growth of mildew on the coating surface. 2. 2004-2023. Wells Created Date:CONTRIBUTION MAXIMUMS FOR EACH BENEFIT ARE BASED ON A. 5. Click . Changes in the credentials at Unified Member Portal will be effective at this Portal after after 6 Hours. What_To_Expect_Next_Flyer_AH_071717 For assistance, please contact the Client Assistance. From your main Benefits screen, you will see the box indicating you have a Balance Due to pay back. - Lusha3 C. Enter your user name and password and then click . The app has been available since September 2020. INSURANCE CO-PAYS: Medical Office Visit Co-Pays: _____ Emergency Room Co. m. 52. com . The thick, elastic film covers, hides and protects for long-lasting durability. CPNFLEX. R. CONSUMER 55 A cPNFLEX Home Accounts Tools & Support Dependents JAX REDER Birth Date: 4/10/2001 Student: No View / Update Message Center Add Dependent Profile / Profile Summary Profile KA THERINE REDER HOME ADDRESS 190 Cross Creek Drive Oakland, TN 38060 United States HOME PHONE (901) 238-9076 EMAIL ADDRESS [email protected] current year maximums. At the top of the page, put your curser over your name as shown in example below and a drop-down boxCall 000-800-440-2008. CST. CPNFLEX. comAll-in-one event platform makes it easy to design a custom experience for your audience - in-person, virtual or hybrid. Call 000-800-440-2008. Mail or fax your application to: HSA Bank, P. com IP Server: 69. Top 10 related websites. Title: Flexible Spending Account (FSA) Tax-Free Transportation/Parking Reimbursement Claim Form Author: Katherine Reder Created Date: 10/18/2012 12:03:29 PMEmployer Contributi on Refund Form Mail or fax completed forms to: Address: HealthEquity, Att n: Client Services 15 W Scenic Pointe Dr, Ste 400, Draper, UT 84020 Fax: 520. The initial Plan Year shall begin on , and end on Future Plan Years will be based on a twelve-month period beginning each• A plan that includes a health FSA may allow (similar to the rules applicable to DCFSA) an employee who ceases participation in the plan during calendar year 2020 or 2021 (for example,Flex Benefits Card . From your main Benefits screen, place your curser over Claims & Payments and select View Claim ActivityEmail: dorothy@cpnflex. Notification . 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and as3 C. COM) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health Reimbursement Arrangement (HRA) with respect to such. 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and asHealth Savings Account (HSA) Application and Eligibility Form Instructions: Complete all fields below. Page 2 of 20 Fileid:. 8244 / (toll free) 800. From Consumer Portal or CPNFLEX Mobile App . Title: ENROLLMENT FORM FOR THE FLEX BENEFITS PLAN Author: Katherine Reder Created Date: 7/12/2021 8:54:50 AMDental – Qualified Expenses (FSA) Dental services and supplies that do qualify unless they are reimbursed by insurance: • Co-payments • Dental fillings, crowns, and bridgesBeginning January 1, 2023, the standard mileage rates for the use of a car (including vans, pickups or panel trucks) is: . This will direct you to… 4. Powerful features of the app include: Easy, Convenient & Secure. $0. Employers may contribute to employees' HSAs. org, ns-1576. Lost/stolen CPNFLEX debit card reporting available 24/7 from participants Consumer Portal, CPNFLEX mobile app, or by submitting a request via email to claims@cpnflex. CONFLEX SILK (BLEACHED KRAFT MG PAPER) 40GSM X1100MM. Employer. 29. CPNFLEX has a content rating "Everyone". 3. By Continental Industries. Contact Information. Learn more about its features, benefits, and application methods in this PDF document. The next page will display three (3) options available to reset: FAQ: If you cannot locate your Username and/or Password to complete the above steps, email CPN’s Customer Service Center at [email protected] (07122023-2224)The information contained in this memo is not intended to be legal, accounting, or other professional advice. Compliance Alert: Mergers and Acquisitions Affect Employee Benefits – Update 9/14/2017. If you did not use your CPNFLEX card and need reimbursed for a qualified expense you paid out-of-pocket, you may submit a claim to CPN for reimbursement. 4. Title: ENROLLMENT FORM FOR THE FLEX BENEFITS PLAN Author: Katherine Reder Created Date: 7/12/2021 8:54:50 AM1-800-737-0125 / 901-756-8244 / 901-756-8322 Fax / claims@cpnflex. Stand-Alone HRAs for Small Employers . 2. The receipt must include the service provider’s name and the date and type of service for each expense. WWW. #cpnflexappnotworking #cpnflexappwontload #cpnflexappproblems #cpnflexmodapkdownloadOctober 10, 2017 . Must money be deposited in my account before I file a claim? NO. We found below. Here you will set up your: a. -. . CPNFLEX. , Member FDIC. 5. DEPENDENT SETUP REQUEST . alan@cpnflex. com pull funds: Lindsay Bovee Email: [email protected]) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health ReimbursementAssume a $5,000 election to the dependent care portion of the plan by a more than-5% owner and elections in the amount of $19,500 made by all non-owners. Employers may contribute to employees' HSAs. com E-mail: Title: Flexible Benefit Plan Claim Form Author: Patricia S. R. , co-pays, deductibles, etc. , CPNFLEX. com (1 seconds ago) / › Adtargeting. Sections is used for grouping other nodes and option is a key-value pair. Warm regards, The CoinFLEX Team. HSA Bank is a division of Webster Bank, N. 3 C. com. 3 C. Save time and hassles while making the most of your HRA and FSA health benefit accounts by quickly checking your balances and details. ConFlex Risers may be installed with or. 514(e)(2)) or, if needed by Business Associate, to the minimum necessary PHI to accomplish the intended purpose of such use, disclosure or request, and as6. All rights reserved. part 1. 62, HostName: 69. Total Health Reimbursement Arrangement . What is the take care® Flex Benefit Plan? It’s a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Toll Free: 800. WWW. 33 out of 5 stars, based on 3 ratings. 2 ½ Month Extension is when a company offers for two months and fifteen days after a plan year ends, any remaining FSA funds left on a prior FSA plan year, to pay first. POR FAVOR IMPRIMIR. GOC_EV1_Form_Proposal_10052022 Group Online Contribution (GOC) Form Please complete and sign this form and the corresponding agreement for group online contributions. © 2023 Tideworks Technology. WWW. 48043900. The receipt must include the service provider’s name and the date and type of service for each expense. It’s free. COM) Read Carefully: When filing your claim, you must attach copies of the receipts. A: Participants who opt to use a CPNFLEX card will not have to pay for their qualified services out of their personal funds and then wait for reimbursement. F. R. A. Title: Flexible Spending Account (FSA) Tax-Free Transportation/Parking Reimbursement Claim Form Author: Katherine Reder Created Date:Radiology Consultants of Little Rock Medical Towers #1 9601 Baptist Health Drive, Suite 1100 Little Rock, AR 72205. Page . ConFlex Flexible is a high-performance, elastomeric coating that protects concrete and masonry surfaces from water intrusion, cracking, and peeling. Wells Created Date:© WEX Health Inc. 3. 756. 4 CPN Limited. PCORI Fees Due by July 31, 2021 . You will need to obtain your EOB (Explanation of Benefits), showing the dates of service, the services rendered, and amount you are responsible for that is applied toward your employer's. How do I get this information, or have it reset? • If you offer the debit card to your employees, you may email Katherine Reder at [email protected]) Read Carefully: The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a period while the undersigned was covered under the Company’s Health Reimbursement Arrangement (HRA) with respect to such. The receipt must include the service provider’s name and the date and type of service for each expense. , Member FDIC.