Letter of Medical Necessity (FSA/HSA)

Who is this for?
Clients using FSA or HSA funds.

Why do I need it?
Some plans require proof that this service supports your health.

When is it needed?
When your FSA/HSA provider asks for medical documentation before reimbursement.

How to Use This Form

Click to download link.

Save the file to your device.

Print it or email it to your healthcare provider.

Ask them to complete and sign it.

Submit the signed letter with your FSA/HSA receipt.

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