Triage Cancer - Medical Bills Worksheet

	A	B	C	D	E	F	G	H	I	J	K	L
1	Medical Bill Tracker
2	Plan Name:		BienStar Gold		Co-Insurance Amount (%)		80/20
3	Deductible Amount		$ 1,000.00		Out-of-Pocket Max		$ 8,000.00
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5	Total Billed YTD		$1,800.00	Paid Out-of-Pocket YTD	$1,000.00	Total Remaining to Meet Deductible	$0.00	This Medical Bill Tracker is a resource provided by Triage Cancer for personal use.Please feel free to share this resource with your communities or to post a link on your organization's website. However, this content may not be reproduced, in whole or in part, without the express permission of Triage Cancer. Please email us at info@TriageCancer.org to request permission. To find more resources on the practical and legal issues that arise after a cancer diganosis, please visit, https://triagecancer.org. © 2022 Triage Cancer
6	Total Paid by Insurance YTD		$800.00	Total Due	$0.00	Total Remaining to Reach Out-of-Pocket Maximum	$7,000.00
7
8	Bill Date	Provider Name	Statement Number	Description of Services	Total Amount Billed	Amount Paid by Insurance	Amount Paid Out-of-Pocket	Amount Due	Method of Payment	Appeal Needed?	FSA/HSA Status	Notes
9	1/12/2025	Dr. Sue	1234	Office Visit	$300.00	$0.00	$300.00	$0.00	Bank Account	No	Submitted
10	1/25/2025	Imaging Center	789	MRI	$1,500.00	$800.00	$700.00	$0.00	Credit Card	No	Need to Submit
11								$0.00
12								$0.00
13								$0.00
14								$0.00
15								$0.00
16								$0.00
17		This worksheet is an example only. To input your own information, click on the sheet to the right called "My Medical Bill Tracker." To use that worksheet, download a copy to your computer and complete the following steps: Step 1: fill out the information in the top 4 rows using information from your health insurance policy. Step 2: as you recieve and pay bills, fill out rows with the information from your Explaination of Benefits (EOB). Each time you add information in rows 9 - 55, the totals at the top and bottom of the sheet will automatically calculate.						$0.00
18								$0.00
19								$0.00
20								$0.00
21								$0.00
22								$0.00
23								$0.00
24								$0.00
25								$0.00
26								$0.00
27								$0.00
28								$0.00
29								$0.00
30								$0.00
31								$0.00
32								$0.00
33								$0.00
34								$0.00
35								$0.00
36								$0.00
37								$0.00
38								$0.00
39								$0.00
40								$0.00
41								$0.00
42								$0.00
43								$0.00
44								$0.00
45								$0.00
46								$0.00
47								$0.00
48								$0.00
49								$0.00
50								$0.00
51								$0.00
52								$0.00
53								$0.00
54								$0.00
55	1/13/2022							$0.00
56				Totals	$1,800.00	$800.00	$1,000.00	$0.00
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