Health Insurance Reimbursement Receipt Request

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We couldn't be more pleased that your insurance company offers a reimbursement on the investment in your health. Hooray for prevention!

This form will give us all the information we need to help you get the right items so you can submit. Thank you for filling it out completely so we can assist you!

Kindly fill out this form below and our Operations Team will forward your receipt within 3 business days. If you have more than one person in your family you are trying to submit for, please fill out one form per family member.

Email: *

First and Last name: *

Dates needed for reimbursement (what year, how many months, etc) *

Is there anything else you need to complete your claim? *

Submit

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