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Client name:
Year:
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MEDICAL TRAVEL AND RECEIPT CHECKLIST
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o   FEES FOR MED/DENTAL PLANo  MENTAL HEALTH THERAPY
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o    PRESCRIPTIONS (request annual statement from pharmacy)o   ACCUPUNCTURE
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o  DENTAL/ORTHODONTICSo   NATUROPATH/HOMEOPATH CONSULTATION ONLY
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o   EYE GLASSES/EXAMSo   DIABETIC SUPPLIES
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o   LAB FEESo   MASSAGE THERAPY
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o  COMMUNITY CAREo   FOOT CARE
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o   NURSING HOMESo   NURSING CARE
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o   HOSPITAL CO-PAYMENT FEESo  MOST OTHER DEVICES AND/OR FEES CHARGED BY A LICENSED MEDICAL PRACTITIONER
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o   ORTHOTICS
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o   CHIROPRACTIC
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MEDICAL TRAVEL
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Mileage may be claimed if you had to travel at least 40km one-way to obtain medical services
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Mileage, accommodation, meal, and parking expenses may be claimed if you had to travel at least 80 km one-way to obtain medical services.
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 Rate0.585
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DateDr. NameCity# of Km's Driven$ of Km's DrivenMealsParking (Receipt Required)Accomodation (Receipt Required)Total
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00
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Total $ -
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