Supportive Document Request
Please complete this form to submit your request. Separate submissions are required for each document requested.
Document Requested:
*
Document for Health Insurance/HSA/FSA Submission
Formal Letter Verification of Diagnosis
Letter of Support
Work Related Document
Proof of Prescribed Medication for Travel
Support for School Accommodations
Disability Related Document
Letter for School
Diagnosis Verification Letter
Treatment Verification Letter
Other
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Starting date of service for which this document is requested:
*
-
Month
-
Day
Year
Date
Specific requests:
Upload Any Document(s) Here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preferred Delivery Method:
*
Email on file
Other
Signature
*
My Products
*
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( X )
Specific Document Review and Completion
Processing and Completion Fee
$
50.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
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