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Dr. Smith Family Practice
123 Main Street
Anytown, CA 12345
Tax ID: 12-3456789
Date: 09/15/2024
Time: 2:30 PM
Patient: John Doe
Service: Office Visit
Consultation: $150.00
Amount Due: $150.00

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Dr. Smith Family Practice - Office Visit

$150.00

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Dr. Smith Family Practice
123 Main Street
Anytown, CA 12345
Tax ID: 12-3456789
Date: 09/15/2024
Time: 2:30 PM
Patient: John Doe
Service: Office Visit
Consultation: $150.00
Amount Due: $150.00

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✓ Date extracted
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Reimbursement Form

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Provider Information

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Visit Details

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Based on provider type

Smart Category Selection

Based on "Dr. Smith Family Practice"

✅

Office Visit

●

Why this matches: Provider name indicates general family practice

HSA Eligible: Regular doctor visits are fully covered

🔄

Preventive Care

○

Choose this if it was a routine checkup or physical exam

👩‍⚕️

Specialist Visit

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Select if Dr. Smith is a specialist in a specific medical field

💡 HSA Eligibility Guide
  • ✓ Doctor visits and consultations
  • ✓ Preventive care and screenings
  • ✓ Prescription medications
  • ✓ Medical procedures and treatments

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CPT Code

A billing code doctors use to describe services. Don't worry - we automatically match these for HSA eligibility.

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Submission Summary

Provider: Dr. Smith Family Practice
Date: September 15, 2024
Amount: $150.00
Category: Office Visit
Status: Processing (1-2 business days)
Next Steps
1 Form submitted
2 Verifying eligibility
3 Processing payment