Mobile # for texting. Don't include "1" in front of phone number.
Date format must be mm/dd/yyyy

Address
e.g. Diabetes (if none, type "none")
If none, type "none"
Medication and/or environmental. If none, type "none".
Just a suggestion... Provider will make final determination.
Provide as much detail as possible
lbs

Costs

Payment
After you submit your request, a licensed medical provider will review your information and you will receive a response via email or text message as soon as possible. Your credit will be charged immediately. Some HSA credit cards might not be accepted if a card processing error is shown.

By clicking the "Submit Request" button below, you confirm that you are the patient or legal guardian thereof, and you agree to the Terms of Use.

You must use your credit card statement billing zip code.
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