Injury Expense Report Template: Medical Cost Reimbursement

Expense Report Related to Injury Template

[Your Full Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

[Phone Number]

[Email Address]

Date of Birth: [MM/DD/YYYY]

1. Injury and Case Information

Type of Incident (check or describe):

• Motor vehicle accident

• Workplace injury

• Slip-and-fall / premises incident

• Assault or violence

• Sports / recreational injury

• DUI-related crash

• Other: [Description]

Motor vehicle accident

Workplace injury

Slip-and-fall / premises incident

Assault or violence

Sports / recreational injury

DUI-related crash

Other: [Description]

Date of Injury: [MM/DD/YYYY]

Location of Injury (City, State/Province): [Location]

Claim / Case Information (if applicable):

Insurance Company: [Name]

Claim Number: [Number]

Attorney / Law Firm (if any): [Name]

Case Number / Court File Number (if any): [Number]

2. Reporting Period

Expense Report Period From: [MM/DD/YYYY]

To: [MM/DD/YYYY]

This report covers all known, injury-related expenses incurred during the above dates.

3. Summary of Expense Categories

(You may complete this section after filling in the detailed entries.)

Medical Treatment (doctors, hospital, ER, clinics): $[Total Amount]

Prescriptions and Medications: $[Total Amount]

Medical Equipment / Supplies (braces, crutches, etc.): $[Total Amount]

Therapy / Rehabilitation / Counseling: $[Total Amount]

Transportation / Mileage / Parking: $[Total Amount]

Home Care / Assistance / Childcare: $[Total Amount]

Lost Wages (if documented here): $[Total Amount]

Other Injury-Related Expenses: $[Total Amount]

Total Injury-Related Expenses for This Period: $[Grand Total]

4. Detailed Expense Entries

(Use as many entries as needed for each expense. Copy or continue on additional pages if necessary.)

Expense 1

Date of Expense: [MM/DD/YYYY]

Provider / Vendor Name: [Hospital, Doctor, Pharmacy, Business]

Provider Type (check one):

• Hospital / Emergency Room

• Doctor / Clinic / Specialist

• Pharmacy

• Therapist / Counselor / Rehab

• Transportation (taxi, rideshare, bus, mileage)

• Medical Equipment / Supplies

• Home Care / Childcare

• Other: [Description]

Hospital / Emergency Room

Doctor / Clinic / Specialist

Pharmacy

Therapist / Counselor / Rehab

Transportation (taxi, rideshare, bus, mileage)

Medical Equipment / Supplies

Home Care / Childcare

Description of Expense:

[Short description, e.g., “Emergency room visit,” “Physical therapy session,” “Prescription medication,” “Taxi to follow-up appointment,” “Knee brace.”]

Category: [Medical Treatment / Medication / Equipment / Therapy / Transportation / Home Care / Lost Wages / Other]

Amount (Currency): $[Amount]

Paid By (check one):

• Self

• Insurance

• Employer / Program

• Other: [Description]

Self

Insurance

Employer / Program

Is Reimbursement Requested for This Item? [Yes / No / Already reimbursed]

Receipt / Invoice Attached? [Yes / No]

Notes (optional):

[Any clarifying information, such as billing date vs. service date, partial payments, or claim numbers.]

Expense 2

Date of Expense: [MM/DD/YYYY]

Provider / Vendor Name: [Name]

Provider Type: [See options above]

Description of Expense:

[Short description]

Paid By: [Self / Insurance / Employer / Other]

Notes:

[Optional]

Expense 3

Expense 4

(Add additional expense blocks as needed.)

5. Transportation and Mileage Log (If Applicable)

Use this section if you claim mileage or transportation costs related to injury treatment.

Trip 1

Date: [MM/DD/YYYY]

Purpose of Trip: [e.g., “Visit to orthopedic specialist,” “Physical therapy session”]

Starting Location: [Address or City]

Destination: [Clinic / Hospital / Provider Address]

Round-Trip Distance: [Number] miles / km

Type of Transportation:

• Personal vehicle (mileage)

• Taxi / Rideshare

• Public transportation

• Other: [Description]

Personal vehicle (mileage)

Taxi / Rideshare

Public transportation

Amount Claimed: $[Amount]

Trip 2

Date: [MM/DD/YYYY]

Purpose of Trip: [Description]

Starting Location: [Location]

Destination: [Location]

Round-Trip Distance: [Number] miles / km

Type of Transportation: [As above]

Amount Claimed: $[Amount]

(Add more trip entries as needed.)

6. Lost Wages Summary (Optional – If Included in This Report)

Employer Name: [Employer]

Employer Address: [Address]

Supervisor / HR Contact: [Name]

Phone / Email: [Contact]

Dates Absent from Work Due to Injury:

From: [MM/DD/YYYY]

To: [MM/DD/YYYY]

Normal Work Schedule: [e.g., “Monday–Friday, 8:00 a.m.–4:30 p.m.”]

Hourly Rate / Salary: [Amount]

Total Hours Missed (if hourly): [Number]

Total Gross Wages Lost (before taxes): $[Amount]

Supporting Documentation (check all attached):

• Employer letter confirming time missed and pay rate

• Pay stubs

• Timesheets or attendance records

• Doctor’s note / work status form

Employer letter confirming time missed and pay rate

Pay stubs

Timesheets or attendance records

Doctor’s note / work status form

7. Reimbursement and Payment Information

Total Injury-Related Expenses Claimed in This Report: $[Total]

Amount Already Reimbursed by Insurance / Other Sources: $[Amount]

Net Amount Requested (if applicable): $[Amount]

Preferred Reimbursement Method:

• Check by mail

• Direct deposit

• Other: [Description]

Check by mail

Direct deposit

Payee Name (for reimbursement checks): [Name]

8. Declaration and Signature

I, [Your Full Name], declare that the information provided in this Expense Report Related to Injury is true and accurate to the best of my knowledge. The listed expenses are directly related to the injury described above. I understand that false or misleading statements may affect my claim or legal rights.

Signature: _______________________________

Printed Name: [Your Full Name]

Date: [MM/DD/YYYY]

9. For Office / Claims Use Only (Optional)

Reviewed By: [Name]

Title / Role: [Adjuster / Claims Representative / Attorney / HR]

Date of Review: [MM/DD/YYYY]

Notes / Determination:

[Brief internal notes, if used by an organization or insurer.]