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Please enter your annual FSA eligible medical expenses into the fields
below(Example: 500).
|
| 1. Medical - Deductibles, Copayments, Coinsurance, Routine Exams. |
| Physician/Doctor:
|
$ |
|
| Osteopathic Physician:
|
$ |
|
| Chiropractor:
|
$ |
|
| Podiatrist: |
$ |
|
| Other Health
Practitioner: |
$ |
|
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| 2. Prescription - Prescription Drugs(Covered &
Non-Covered), Copayments, Coinsurance. |
| Pharmacy: |
$ |
|
| |
| 3. Hospital - Deductibles, Copayments, Coinsurance. |
| Hospitals: |
$ |
|
| |
| 4. Dental/Orthodontist - Deductibles, Copayments,
Coinsurance, Routine Exams. |
| Dentist/Orthodontist:
|
$ |
|
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| 5. Vision - Prescription Eyeglasses & Contacts
Lenses, Deductibles, Copayments, Coinsurance. |
| Optometrist: |
$ |
|
| Ophthalmologist:
|
$ |
|
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| 6. Supplies - Contact Lens Supplies, Medical and Dental
supplies |
| Medical/Dental/Vision:
|
$ |
|
| Orthopedic Goods:
|
$ |
|
| Hearing Aids:
|
$ |
|
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| 7. Laboratory - X-Ray/ Lab Fees |
| Medical/Dental
laboratory: |
$ |
|
The tax savings computation is based on 2009 Tax Tables, assumes various tax deductibles, and does not consider state and local taxes. Actual savings will vary based on your individual tax situation. Please consult a tax professional
for more information on tax implications of an FSA. |
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