Medical Questionnaire - 2019
Please use this Questionnaire if your medical expenses are or might be over 7.5% of you income, or if you are not sure.
Please use DROPBOX.com to send documents. Alternatively, you can mail or drop off at mail slot at my home office.
Email address *
Last Name *
Your answer
First Name *
Your answer
Did you pay any of these expenses - Out of Pocket (NOT taken out of your paycheck) *
Yes
No
I am not sure!
Health Insurance
Dental Insurance
Medicare Premiums
Long Term Care Premiums
Prescriptions
Fees for Doctors, Dentists, Orthodontist, etc
Fees for Hospitals, clinics, etc
Eyeglasses or contact lenses
Hearing Aids
Medical Equipment and Supplies
Long Term Care
Mileage or Transportation
Lodging over night
Other (List in Section 4 - Additional Information)
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy