Transaction Report

Reasons For Request
- Taxes
- HSA/HRA
- Balance Update
If Reason Above is Other, Enter Reason Here:
Type of Inquiry:
- Charges Only
- Payments Only
- Both Charges and Payments
Name*
First Last
Email
Phone*
Address
Street Address Address Line 2 City State ZIP Code
Dates of Service
- All Dates
- Specific Dates
Dates Of Service From:
Date Format: YYYY dash MM dash DD
Date Of Service To:
Date Format: YYYY dash MM dash DD
Please include any other information you feel we may need to process your request:
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