2021 Medical Expense Template

 Instructions: Please fill out this medical expense template and return to our office. Medical expenses include Dr & Dentist visits, eyecare visits, contacts, eyeglasses, hospital visits etc. Medical mileage is round trip mileage to and from Dr & Dentist visits, eyecare visits, pharmacy visits, hospital visits etc. Pharmacy expenses are expenses incurred for prescription drugs only. Insert additional lines if necessary. If you need assistance please contact our office.

Medical Expenses

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Medical Mileage

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Pharmacy Expenses

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