Let’s work together Name * First Name Last Name Email * Practice Name What services did you provide In-Person Telehealth Date services started MM DD YYYY Date of invoice MM DD YYYY Confidential Patient Identifier For example, assign a patient a reference number so that subsequent forms can categorized appropriately. Ex: Ref# 101 Total Number of Billable Hours For This Invoice Total Amount To Be Paid For This Invoice Please Include Payment Link If Applicable If check is to be sent: provide mailing address Thank you for your reimbursement request. Please contact teampay@crossfit.com for additional questions.
