commonplace

HSA/FSA Reimbursement Intake

Complete this short form to receive your Letter of Medical Necessity.

About You

Address

Your Plan

Medical

About You

Basic info for your Letter of Medical Necessity.

First Name

Last Name

Email Address

Phone Number

Date of Birth

Required for your signed LMN document.

Street Address

Apt / Suite

City

State

ZIP Code

SSN Last 4 Digits

Required for IRS documentation

Tell us what you're purchasing and where your HSA/FSA is held.

Product / Device

Pre-filled from the product page — edit if needed

HSA / FSA Administrator

Employer Name

Helps the reviewing provider write your LMN accurately.

Medical Condition / Reason for Use

A licensed provider will review your case within 1–2 business days. We'll email you when your Letter of Medical Necessity is ready to download.