Act Natural
Health & Wellness, LLC
HSA-FSA Prescription Form 
Natural supplements and vitamins may be reimbursed through your Flexible Spending Account or Health Savings Account when your prescribing healthcare provider recommends specific supplements for specific health reasons. Your healthcare practitioner can use this HAS-FSA Prescription Form.
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 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 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 .
Health Savings Account (HSA) and Flexible Spending Account (FSA) Information for Submission of Natural Supplement Costs
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 |
