Receipt Request Form- Integra Acupuncture
Request a receipt for insurance reimbursement, your HSA, HRA, FSA, etc. accounts, or for your taxes!
First Name
Your answer
Last Name
Your answer
What is your current street address?
Your answer
What is your current City, State, & Zip?
Your answer
Please specify what you are being seen for:
For Example: Lower Back Pain, Right Shoulder Pain, Migraines, Fertility, etc.
Your answer
What/who is the receipt for?
Dates of Service Requested
Specific Dates Requested
Example: January to April, or September 14th- September 27th
Your answer
Email Address
We will send your requested receipt to this email address
Your answer
Submit
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