UNREIMBURSED MEDICAL ITEMIZATION FORM

YEAR

PLAINTIFF	DEFENDANT	CASE #

DEPENDENT FOR WHOM EXPENSES INCURRED
(only one per page)

Deductible Met: Yes No

Plaintiff’s share of unreimbursed expenses	%
Defendant’s share of unreimbursed expenses	%

Medical Service Date	Service Provider & type of service	Total Bill Amount	Insurance Reimbursement

Amount	Total Balance	Plaintiff Paid	Defendant Paid	Balance Due by Defendant	Payable to Whom

Total:

Plaintiff signature___________________________	Date__________________

MB-001 / MED EXP

UNREIMBURSED MEDICAL EXPENSE FORM

Rachel A Wotring

2017-02-03

Commonwealth of Pennsylvania - PACSES