Peak Performance HydrationHSA / FSA RECEIPT
42201 N 41st Dr, Suite 122
Phoenix, AZ 85086
(623) 282-1201
peakperformancehydration.com
For reimbursement
HSA / FSA receipt.
A blank receipt you can hand-fill. For an itemized, auto-filled superbill from a specific visit, sign in to your member portal.
| Field | Details |
|---|
| Patient name | |
| Date of service | |
| Service (CPT 96365, IV infusion) | |
| Provider | Peak Performance Hydration |
| Provider NPI | |
| Amount paid | $ |
For HSA / FSA reimbursement: Submit this receipt to your plan administrator. IV vitamin therapy provided under medical supervision is generally an eligible expense. Confirm specifics with your plan. Prefer an itemized superbill? Sign in to the member portal to generate one for any completed visit.