Hsa & Fsa itemized receipt request

Hsa & Fsa itemized receipt request

Please complete this form in detail. You will receive a receipt via email within 72 business hours
Full Name*

First NameLast Name
Employer:
example@example.com
E-mail
example@example.com
Name of service received exactly as listed on your confirmation:
Cost of service:
Include the exact amount(s) that should be reflected
Date deposit or full payment was made:

MonthDayYear
Date
Date the service was received:

MonthDayYear
Date
Please list the deposit amount & Final balance paid including tip if applicable
Is your employer requesting any additional information not listed or any additional forms? Please explain
If a Medical necessity form is required please email it to: support@davonnaskinclinic.com
Please be sure to complete all information outlined above exactly as requested to ensure your recipt is accurate and we can provide it to you effeciently. Please note that Davonna Skin Clinic does not have authority to approve claims on your behalf. It is up to your employer to render benefits based on the guidlines and regulations they set in place. If they do not approve your claim you will have to follow up with them directly.
Should be Empty: