Line
|
Provider Name
(Name of doctor, hospital,dentist,etc)
|
Person
Receiving
Service
|
Date(s)
Expense(s)
Incurred
|
Expense Type
(check one)
Med Dent Misc
|
Total Expenses
|
Amount Paid by Insurance
|
Amount Paid by
You
|
||
1
|
|
|
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
|
|
4
|
|
|
|
|
|
|
|
|
|
5
|
|
|
|
|
|
|
|
|
|
6
|
|
|
|
|
|
|
|
|
|
7
|
|
|
|
|
|
|
|
|
|
8
|
|
|
|
|
|
|
|
|
|
|
Totals
|
$
|
$
|
$
|