If you pay out-of-pocket and don’t have an itemized receipt, you can include these completed forms when you file a claim from your Forma account.
You can also use this form for expenses paid with your Pre-tax Forma Card when asked for substantiation.
Attach the form along with your other supporting documents such as an emailed invoice, bank statement, or other proof of payment when filing your claim.
Please note that only completed services can be reimbursed. Please list service start and end dates on the form so that Forma’s claim review team can better verify eligibility.