- Acupuncture
- Herbal Medicine
- Nutritional Guidance
- Supplemental Direction
- Lifestyle Feng Shui
- Emotional Balancing
- Integrative Medicine (Western)
Name: ________________________________________________________________ Date of Birth: __________________________________________________ Prescribing Healthcare Provider’s name: ________________________________ Prescribing Healthcare Provider’s address: ______________________________
Diagnosis/diagnoses:
Natural / Dietary Supplements recommended for health plan:
I recommend the above natural supplements as part of this patient’s health plan, to address specific concerns associated with his/her health status.
Signature Prescribing Healthcare Provider Date
DOM, L.Ac.
where love and light meet
science and technology
2716 San Pedro Ste. A
ABQ, NM 87110
505-999-9468
www.bodyvolve.com
Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) Reimbursements
Issues of Reimbursements
Many Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) allow individuals to pay for needed natural supplements with pre-tax dollars. Using these accounts can save people 20 to 30% of the final costs of these goods. However, in order to qualify for reimbursement, most plans require a signed form from your prescribing healthcare provider outlining your diagnosis and stating that the supplement recommended may be useful in improving your health.
To investigate getting reimbursed for dietary supplements, steps include:
- Visit your prescribing healthcare provider to discuss integrating natural supplements into your plan of care.
- Your Provider must write and sign a letter including your diagnosis and his/her recommendation of specific supplements for that health reason OR
- Use this form to assist your prescribing healthcare provider with supplying the information necessary to determine if your HSA/FSA account may be used to cover the costs of supplements.
Please note that some insurance carriers and HSA/FSA administrators ask that the message from the health care provider come to them on office letter head or a prescription pad to validate that the authorizing letter did indeed originate from the prescribing health care provider's office. Therefore, if choosing to use our sample information form, you may want to consider asking your provider to staple a piece of their office letterhead stationary to the form to validate that it originated from their office.
Insurance Reimbursement FormIssues of reimbursements
Many Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) allow individuals to pay for needed Natural Supplements with pre-tax dollars. Using these accounts can save people 20 to 30% of the final costs of these goods. However, in order to qualify for reimbursement, most plans require a signed form from your prescribing healthcare provider outlining your diagnosis and stating that the supplement recommended may be useful in improving your health.
To investigate getting reimbursed for Natural Supplements, steps include:
1. Visit your prescribing healthcare provider to discuss integrating natural / dietary supplements into your plan of care.
2. Your Provider must write and sign a letter including your diagnosis and his/her recommendation of specific supplements for that health reason OR
3. Use this form to assist your prescribing healthcare provider with providing the information necessary to determine if HSA/FSA account may be used to cover the costs of supplements.
Please note that some insurance carriers and HSA/ FSA administrators ask that the message from the healthcare provider come to them on office letter head or a prescription pad to validate that the authorizing letter did indeed originate from the prescribing healthcare provider’s office. Therefore, if choosing to use our sample information form, you may want to consider asking your provider to staple a piece of their office letterhead stationary to the form to validate that it originated from their office.
For further information on what is eligible for HSA/FSA reimbursement visit the IRS website at http://www.irs.gov/pub/irs-pdf/p502.pdf .