Receipt Request Form- Integra Acupuncture
Request a receipt for insurance reimbursement, your HSA, HRA, FSA, etc. accounts, or for your taxes!
What is your current street address?
What is your current City, State, & Zip?
Please specify what you are being seen for:
For Example: Lower Back Pain, Right Shoulder Pain, Migraines, Fertility, etc.
What/who is the receipt for?
HSA-Health Savings Account
HRA-Health Reimbursement Account
FSA-Flexible Spending Account
Other Insurance Reimbursement
Dates of Service Requested
I would like a receipt for all of the appointments I've ever had- All Dates of Service
I would like a receipt for specific dates- INPUT BELOW
Specific Dates Requested
Example: January to April, or September 14th- September 27th
We will send your requested receipt to this email address
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