MEDICAL EXPENSE REIMBURSEMENT WORKSHEET

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Medical doctors' fees Annual physical examinations Dental examinations Eye examinations Eyeglasses Contact lenses and solutions Prescription drugs X-rays Lab fees Hospital services Chiropractors Hearing aids Surgery Ambulance service Dentures Acupuncture Orthodontics Over-the-counter medications/supplies TOTAL ESTIMATED ANNUAL EXPENSES NUMBER OF PAY PERIODS (required) AMOUNT OF PAY PERIOD REDUCTION MEDICAL EXPENSE REIMBURSEMENT WORKSHEET This worksheet will help you estimate your annual medical costs which will not be reimbursed by a health insurance plan. This list is not intended to be comprehensive, but it contains some of the more common medical expenses. List all costs incurred by you, your spouse or qualified dependent that will not be reimbursed with other coverage. Qualifying Expense Phone: 937-865-6500 Email: [email protected] myCafeteriaPlan 432 E Pearl Street, Miamisburg, OH 45342 Estimated Annual Expense

Transcript of MEDICAL EXPENSE REIMBURSEMENT WORKSHEET

Page 1: MEDICAL EXPENSE REIMBURSEMENT WORKSHEET

Medical doctors' fees

Annual physical examinations

Dental examinations

Eye examinations

Eyeglasses

Contact lenses and solutions

Prescription drugs

X-rays

Lab fees

Hospital services

Chiropractors

Hearing aids

Surgery

Ambulance service

Dentures

Acupuncture

Orthodontics

Over-the-counter medications/supplies

TOTAL ESTIMATED ANNUAL EXPENSES

NUMBER OF PAY PERIODS (required)

AMOUNT OF PAY PERIOD REDUCTION

MEDICAL EXPENSE REIMBURSEMENT

WORKSHEETThis worksheet will help you estimate your annual medical costs which will not be reimbursed by a health insurance plan.

This list is not intended to be comprehensive, but it contains some of the more common medical expenses.

List all costs incurred by you, your spouse or qualified dependent that will not be reimbursed with other coverage.

Qualifying Expense

Phone: 937-865-6500 Email: [email protected]

myCafeteriaPlan

432 E Pearl Street, Miamisburg, OH 45342

Estimated Annual Expense

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