Worksheet: unpaid medical, dental & vision care expenses




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WORKSHEET: UNPAID MEDICAL, DENTAL & VISION CARE EXPENSES
Mother’s Name: Mother’s share of all unpaid expenses listed on this sheet is %*

Father’s Name: Father’s share of all unpaid expenses listed on this sheet is %*



TOTAL: 100%

*(See your Child Support Order, DR 300, page 5, No. 10, which shows % each parent pays for uncovered health care expenses.)

Attach copies of all medical bills and Explanation of Benefits from the insurance company showing the amount it paid.


When was visit to Dr. or health care provider (oldest to recent)?

What is the name of Dr. or health care provider?

How much did the visit cost?

How much did Mom’s insurance pay?

How much did Dad’s insurance pay?

How much $ is still owed to Dr. after insurance paid?

How much did Mom pay out of pocket?

How much did Dad pay out of pocket?

How much does Mom still owe on the bill?

How much does Dad still owe on the bill?



































































































































































































































































































































































































































































Totals for this sheet


$

$

$

$

$

$

$

$




WORKSHEET – UNPAID MEDICAL, DENTAL & VISION EXPENSES Page of

SHC-1541 (11/11)




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