Medical Expense Reimbursement Worksheet
CHANCELLOR & CHANCELLOR, INC. SECTION 125 PLAN MEDICAL EXPENSE REIMBURSEMENT WORKSHEET This worksheet will help you estimate your annual medical costs which may not be reimbursed by a health plan. This list is not intended to be comprehensive, but it contains some of the more common medical expenses. Please review the list on the Medical Reimbursement Allowance page for additional qualifying medical care expenses.
List all costs that are not reimbursed by other coverage incurred by you, your spouse or qualified dependents:
QUALIFYING EXPENSE ESTIMATED ANNUAL EXPENSE Medical doctor's fees $________________
Annual physical examinations ________________
Dental examinations ________________
Eye examinations ________________
Eyeglasses ________________
Contact lenses ________________
Prescription drugs ________________
X-rays ________________
Lab fees ________________
Hospital services ________________
Chiropractors ________________
Hearings aids ________________
Surgery ________________
Ambulance service ________________
Nursing home costs ________________
False teeth ________________
Psychiatrists ________________
Psychologists ________________
Acupuncturists ________________
Orthodontists ________________
_______________________________ ________________
_______________________________ ________________
_______________________________ ________________
TOTAL ESTIMATED ANNUAL EXPENSES $_____________________(A)
NUMBER OF PAY PERIODS _____________________(B)
AMOUNT OF REDUCTION PER PAY PERIOD (A/B) $_____________________