Image 1 of 1
HSA/FSA Eligibility Support Form for Menopause Coaching Services
Reset & Renew Health Coaching LLC
Client Name: ____________________________________
Date of Birth: ____________________________________
Phone Number: ____________________________________
Email: ____________________________________
Coaching Program Selected:
☐ 60-Minute Private Session
☐ GLP+ RESET™ – 12 Week Coaching Program
☐ The Menopause Reset Method – 12 Weeks
☐ Monthly Membership
☐ Other: ____________________________________
HSA/FSA Submission Support Request
I am requesting a support document or receipt for the use of HSA or FSA funds toward eligible menopause wellness coaching services. I understand that it is my responsibility to verify eligibility with my HSA/FSA administrator and that reimbursement is not guaranteed.
Please select:
☐ I need an itemized invoice for my HSA/FSA claim
☐ I need a summary letter of services for eligibility support
☐ I need a letter of medical necessity (LMN) to provide to my physician
☐ I already have documentation and just need a receipt
Consent & Acknowledgement
By signing below, I confirm that I am using a valid Health Savings or Flexible Spending Account in accordance with IRS guidelines and/or my provider’s policies. I understand Reset & Renew Health Coaching LLC is not responsible for the outcome of my HSA/FSA claim.
Signature: ____________________________________
Date: _______________________
📩 For questions, contact: darby@resetrenewhc.com
🌐 Learn more: www.resetandrenewhc.com
Attached is the form on How To Guide for your HSA/FSA:
https://bit.ly/HSA-FSAform
