Act Natural 

         Health & Wellness, LLC

   Act Natural Health & Wellness

                           the way life used to be

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 .


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: _____________________________________







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

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