Karen Dogans

Equipped with strong problem-solving abilities, willingness to learn, and excellent communication skills. Poised to contribute to team success and achieve positive results. Ready to tackle new challenges and advance organizational objectives with dedication and enthusiasm.

Proficient in Microsoft Word and Outlook suites, Kronos/UKG time management/payroll, EPIC registration, Calabrio One workforce management, WebEx meeting and messaging, Cisco phone communication and RightFax systems

• Program Sponsor: Froedtert ThedaCare Health, Inc.
• Karen E Dogans (# 33452965)
• 1135 CARLISLE AVE
• RACINE, WI 53404
• Date Printed: 2026-03-14
• TOLL-FREE FAX: 877-353-9236
• Questions? login.wageworks.com
• Or, mail to Claims Administrator, PO Box 14053, Lexington, KY 40512
• INSTRUCTIONS
• IRS regulations require that 100% of your card transactions be verified (to show your plan benefits were used to pay for eligible expenses). If you are not able to verify your card transactions, then you are required to repay your account. Failure to submit sufficient proof or repayment may result in suspension or loss of your card privileges and possibly tax penalties.
• 1. For each unverified card transaction below, do one of the following:
• A. Submit a detailed / itemized receipt, health plan or insurance company Explanation of Benefits (EOB) or other proof of service. A credit card receipt is not sufficient.
• I. Your detailed receipt must include: date of service, description of service, patient name, provider name and your cost (amount of patient financial responsibility).
• Ii. Please note the corresponding CARD ID number on each receipt or substitute receipt to ensure desired processing.
• B. Submit a repayment check in the amount of the unverified card transaction. Your check should be made out to: WageWorks.
• 2. Submit this form along with your receipt or repayment check as soon as possible.
• CERTIFICATION
• I certify that the information on this form is accurate and complete.
• ABOUT YOUR ORIGINAL CARD TRANSACTION
• Date: 2026-01-29
• Merchant/Provider: WISNOVA RACINE
• Transaction Amount: $290.00
• Unverified Amount: $290.00
• RECEIPT OR REPAYMENT NEEDED
• What are you submitting for this card transaction?
• Actual Receipt OR Substitute Receipt
• Check to Repay Amount
• Amount of Receipt or Check Submitted: $
• CARD ID: 347327751
• HOW TO RESOLVE A CARD TRANSACTION THAT REQUIRES A RECEIPT OR REPAYMENT
• IRS regulations require that 100% of your card transactions be verified (to show your plan benefits were used to pay for eligible expenses).
• Your options to resolve each card transaction listed above are:
• 1. Submit a copy of the detailed receipt for the actual card transaction that contains the service date, service description, patient name, provider name and your cost.
• 2. Submit a copy of any number of substitute receipt(s) for any eligible products and services that you did not and will not pay for using funds in your health care account.
• A. The receipt(s) must include the service date, service description, patient name, provider name and your cost (amount of patient financial responsibility).
• B. The substitute receipt(s) must be for an eligible expense incurred by an eligible dependent during the same coverage period as the card transaction to be verified.
• 3. Send a check to repay your account for the above amount if you no longer have the detailed receipt or if you accidentally used your card to pay for ineligible expenses.
• A. The amount that is repaid will be available to pay for other eligible expenses you incur during your plan year.
• Any amount of card transactions that remains unverified 90 days after the card transaction date will be automatically deducted from any future Pay Me Back claim payments.
• Reminder: Failure to submit appropriate proof or repayment for your card transactions will result in suspension / loss of your card privileges and possibly tax penalties.
• DR 1
• PS 30171
• AH 33452965
• 2026-03-14