Medical Expense Spreadsheet.xlsx
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ABCDEFGHIJKLMNOPQRSTUVWXYZ
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MEDICAL EXPENSES & CLAIMS
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YEAR ______
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Note: to access an editable copy of this spreadsheet, go to File > Make a Copy or File > Download as: Microsoft Excel
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FAMILY MEMBER: ______________________________
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DATEPROVIDERDESCRIPTION OF SERVICEEOB RECEIVED?AMOUNT
BILLED
INSURANCE AMOUNT PAIDCOPAY
AMOUNT PAID
DEDUCTIBLE AMOUNT PAIDAMOUNT
STILL DUE
METHOD OF PAYMENTNOTES
7
0.00
8
0.00
9
0.00
10
0.00
11
0.00
12
0.00
13
0.00
14
0.00
15
0.00
16
0.00
17
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 0.00 0.00 0.00 0.00
27
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FAMILY MEMBER: ______________________________
29
30
DATEPROVIDERDESCRIPTION OF SERVICEEOB RECEIVED?AMOUNT
BILLED
INSURANCE AMOUNT PAIDCOPAY
AMOUNT PAID
DEDUCTIBLE AMOUNT PAIDAMOUNT
STILL DUE
METHOD OF PAYMENTNOTES
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 0.00 0.00 0.00 0.00
51
52
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FAMILY MEMBER: ______________________________
54
55
DATEPROVIDERDESCRIPTION OF SERVICEEOB RECEIVED?AMOUNT
BILLED
INSURANCE AMOUNT PAIDCOPAY
AMOUNT PAID
DEDUCTIBLE AMOUNT PAIDAMOUNT
STILL DUE
METHOD OF PAYMENTNOTES
56
0.00
57
0.00
58
0.00
59
0.00
60
0.00
61
0.00
62
0.00
63
0.00
64
0.00
65
0.00
66
0.00
67
0.00
68
0.00
69
0.00
70
0.00
71
0.00
72
0.00
73
0.00
74
0.00
75
0.00 0.00 0.00 0.00 0.00
76
77
FAMILY MEMBER: ______________________________
78
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DATEPROVIDERDESCRIPTION OF SERVICEEOB RECEIVED?AMOUNT
BILLED
INSURANCE AMOUNT PAIDCOPAY
AMOUNT PAID
DEDUCTIBLE AMOUNT PAIDAMOUNT
STILL DUE
METHOD OF PAYMENTNOTES
80
0.00
81
0.00
82
0.00
83
0.00
84
0.00
85
0.00
86
0.00
87
0.00
88
0.00
89
0.00
90
0.00
91
0.00
92
0.00
93
0.00
94
0.00
95
0.00
96
0.00
97
0.00
98
0.00
99
0.00 0.00 0.00 0.00 0.00
100
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