Personal Submission Health Costs
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Submission Health Care Costs. You will receive SPURT.
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MySPURT account #
xxxxxxxxFull name of account holder:xxxxxxxxxDATExxxxxAttempts to claim a benefit without documentation or receipts in your name may result in the permanent cancellation of your SPSO membership.
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The name of my Health Coach isxxxxx
I don't have a Health Coach yet. Please connect me.
Yes/no
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Send the completed form with supporting documentation to info-at-soundprosperity. org, if possible after approval of the Health Coach.
Date of bill mm/dd/yy
Alternative treatmentsGym
Health equipment
Healthy food
Health Insurance
Other Doctor bills
(Online) classes for Health, and Personal GrowthTravel costs to doctors, hospitals for you and your family
Supplements
Other, explain under Short descriptionOther, explain under Short description
Total amount you
will receive in SPURT
Short Description for OtherPAID DATE
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Add here name of doctor, supplierIn each column, enter the amounts you paid. Enter values in Euros or US Dollars.
If your expenses are in another currency, calculate the value in Dollars.
0.002018-02-15
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