ZAGG XTR2 Screen Protector iPhone 14 Pro Instructions
- June 9, 2024
- ZAGG
Table of Contents
XTR2 Screen Protector iPhone 14 Pro
Instructions
XTR2 Screen Protector iPhone 14 Pro
LETTER OF MEDICAL NECESSITY
Instructions
Flex Spending Accounts (FSA) / Health Reimbursement Arrangement (HRA) /
Health Savings Accounts (HSA) Under IRS guidelines, some health care products
may be eligible for (a) reimbursement through an FSA/HRA, or (b) treatment as
a tax-free distribution from an HSA if it can be shown that the products are
needed primarily for a medical purpose. If a doctor has diagnosed a medical
condition and recommended an InvisibleShield® VisionGuard with Eyesafe®
Technology blue light screen filter as treatment or mitigation for the
condition, it may qualify for reimbursement through an FSA/HRA and/ or for
tax-preferred treatment for an HSA. To qualify for reimbursement, a claim must
include a Letter of Medical Necessity from an optometrist, ophthalmologist, or
other medical doctor.
Medical reimbursement plans and reimbursement polices may vary. While we
cannot guarantee reimbursement in all cases, we recommend the following:
- Submit your claim using the claim form provided by your FSA or HRA administrator, if available.
- Always include a copy of the receipt of your purchase.
Ask your doctor to write a Letter of Medical Necessity on their letterhead. If
that is not available, we have included a sample Letter of Medical Necessity
below.
Doctors: If your patient participates in an FSA, HRA or HSA program, and the
patient purchases an InvisibleShield VisionGuard with Eyesafe Technology blue
light screen filter pursuant to your recommendation to treat or mitigate a
medical condition you have diagnosed, your patient may be eligible for
reimbursement and/or tax-preferred treatment under that FSA, HRA or HSA
(subject to any additional limitations or conditions of the plan).
A sample Letter of Medical Necessity is below, that may be used with your
reimbursement request from a FSA or HRA, or retained for your record if you
purchase the product with funds from your HSA.
LETTER OF MEDICAL NECESSITY
TO BE FILLED OUT BY PARTICIPANT
PATIENT NAME……………………….
PARTICIPANT NAME………………..
PARTICIPANT EMPLOYER……………….
MEMBER NUMBER…………………..
TO BE FILLED OUT BY DOCTOR
DIAGNOSIS| dry eye
digital eye
strain (red, irritated eyes, soreness, fatigue, headaches)
blurred or double vision trouble sleeping
---|---
TREATMENT| InvisibleShield VisionGuard with Eyesafe Technology blue light
screen filter for smartphone and/or tablet device.
This treatment is medically necessary to treat or mitigate the condition
described above; it is not for general health and is not for cosmetic
purposes.
PRINT NAME|
SIGNATURE|
DATE|
ADDRESS|
PHONE|
Patient: Mail or fax this form (and a copy of your receipt) to your FSA/HSA
Administrator (or retain for your HSA records).
Certain expenses may require additional documentation. Please check with your
provider for a detailed description of documentation needed.
Read User Manual Online (PDF format)
Read User Manual Online (PDF format) >>