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Medical Expense Summary Template
Clearly summarize all medical expenses in one organized document for insurers, attorneys, or personal records.
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Medical Expense Summary Template
[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]
1. Case, Claim, or Reference Information
Type of Matter (check or describe):
Motor vehicle accident (may include DUI-related)
Workplace injury
Slip-and-fall / premises incident
Illness or medical condition
Other personal injury or legal matter
Other: [Describe]
Date of Injury / Onset of Condition: [MM/DD/YYYY]
Insurance Company (if applicable): [Name]
Claim Number: [Number]
Attorney / Law Firm (if applicable): [Name]
File / Case Number: [Number]
2. Summary Period
This Medical Expense Summary covers services and bills for the period:
From: [MM/DD/YYYY]
To: [MM/DD/YYYY]
(You can prepare separate summaries for different time periods if needed.)
3. Category Totals Overview
(Complete this section after filling in the detailed entries.)
Hospital / Emergency Care: $[Total Amount]
Physician / Clinic Visits: $[Total Amount]
Therapy / Rehabilitation / Counseling: $[Total Amount]
Diagnostic Tests (X-ray, MRI, CT, lab, etc.): $[Total Amount]
Prescription Medications: $[Total Amount]
Over-the-Counter Medications / Supplies: $[Total Amount]
Medical Devices / Equipment (braces, crutches, etc.): $[Total Amount]
Home Health / Nursing / Caregiving: $[Total Amount]
Other Medical Expenses: $[Total Amount]
Total Medical Expenses for This Period: $[Grand Total]
Optional breakdown:
Amount Paid by Insurance / Other Programs: $[Amount]
Amount Paid Out of Pocket (by you): $[Amount]
Amount Currently Outstanding / Unpaid: $[Amount]
4. Detailed Medical Expense Entries
(Use one block per bill or charge. Copy or extend this section as needed.)
Expense Entry 1
Line Item No.: [1]
Date of Service: [MM/DD/YYYY]
Date of Bill / Statement: [MM/DD/YYYY]
Provider / Facility Name: [Hospital / Doctor / Clinic / Lab / Pharmacy]
Provider Type (check one):
Hospital / Emergency Room / Urgent Care
Physician / Clinic / Specialist
Therapist / Counselor / Rehabilitation
Diagnostic (lab, imaging, tests)
Pharmacy (prescription)
Pharmacy / Store (over-the-counter)
Medical Equipment / Supplies
Home Health / Nursing
Other: [Describe]
Service or Item Description:
[Short description, e.g., “ER visit,” “Follow-up office visit,” “MRI of lumbar spine,” “Physical therapy session,” “Prescription – medication name and dosage,” “Knee brace,” etc.]
Category: [Match one of the categories in Section 3]
Financial Details
Billed Amount: $[Amount]
Insurance Adjustments / Write-offs: $[Amount, if known]
Amount Paid by Insurance or Other Program: $[Amount]
Amount Paid by You (out of pocket): $[Amount]
Amount Currently Outstanding (unpaid): $[Amount]
Payment Date(s) (if any): [MM/DD/YYYY or “Pending”]
Receipt / Bill / EOB Attached? [Yes / No]
Notes (optional):
[Example: “Payment plan in place,” “Co-pay only,” “Pending appeal,” etc.]
Expense Entry 2
Line Item No.: [2]
Date of Service: [MM/DD/YYYY]
Date of Bill / Statement: [MM/DD/YYYY]
Provider / Facility Name: [Name]
Provider Type: [Choose from list above]
Service or Item Description:
[Short description]
Category: [Category]
Billed Amount: $[Amount]
Insurance Adjustments / Write-offs: $[Amount]
Amount Paid by Insurance or Other Program: $[Amount]
Amount Paid by You (out of pocket): $[Amount]
Amount Currently Outstanding (unpaid): $[Amount]
Payment Date(s): [MM/DD/YYYY or “Pending”]
Receipt / Bill / EOB Attached? [Yes / No]
Notes:
[Optional]
Expense Entry 3
Line Item No.: [3]
Date of Service: [MM/DD/YYYY]
Date of Bill / Statement: [MM/DD/YYYY]
Provider / Facility Name: [Name]
Provider Type: [Choose from list above]
Service or Item Description:
[Short description]
Category: [Category]
Billed Amount: $[Amount]
Insurance Adjustments / Write-offs: $[Amount]
Amount Paid by Insurance or Other Program: $[Amount]
Amount Paid by You (out of pocket): $[Amount]
Amount Currently Outstanding (unpaid): $[Amount]
Payment Date(s): [MM/DD/YYYY or “Pending”]
Receipt / Bill / EOB Attached? [Yes / No]
Notes:
[Optional]
(Add additional expense entry blocks as needed.)
5. Prescription and Pharmacy Expense Log (Optional)
Use this section if you have many medication-related expenses.
Medication Entry 1
Medication Name: [Name]
Dosage and Quantity: [e.g., “10 mg, 30 tablets”]
Date Filled: [MM/DD/YYYY]
Pharmacy Name: [Name]
Total Cost: $[Amount]
Insurance Coverage: $[Amount]
Paid by You: $[Amount]
Notes (e.g., “recurring monthly prescription”): [Text]
Medication Entry 2
Medication Name: [Name]
Dosage and Quantity: [Details]
Date Filled: [MM/DD/YYYY]
Pharmacy Name: [Name]
Total Cost: $[Amount]
Insurance Coverage: $[Amount]
Paid by You: $[Amount]
Notes: [Text]
(Repeat as needed.)
6. Explanation of Totals and Method
Briefly explain how you calculated the totals in this summary (for example, what time period you used and whether amounts reflect only your out-of-pocket costs or full billed amounts).
Explanation:
[Free-text narrative, e.g., “Totals include all bills for treatment related to my injury from [date] through [date]. The ‘Total Medical Expenses’ figure reflects the full billed amount before insurance. I also list separate totals for amounts paid by insurance and by me.”]
7. Attachments Checklist
Check all supporting documents attached or available:
Hospital and clinic bills
Emergency room records and statements
Physician / specialist office bills
Physical therapy / rehabilitation bills
Counseling or mental health bills
Diagnostic test bills (X-ray, MRI, CT, lab)
Pharmacy receipts and medication printouts
Receipts for medical devices or equipment
Explanation of Benefits (EOBs) from insurers
Proof of payments (bank or card statements, receipts)
Other: [Describe]
8. Declaration and Signature
I, [Your Full Name], declare that this Medical Expense Summary is true and accurate to the best of my knowledge and is based on the bills, receipts, and records currently in my possession. I understand that this summary may be used by insurance companies, attorneys, or other parties to review my medical expenses related to the incident or condition described above.
I agree to provide additional documentation or clarification if reasonably requested.
Signature: _______________________________
Printed Name: [Your Full Name]
Date Signed: [MM/DD/YYYY]
Place Signed (City, State/Province): [Location]
9. For Office / Claims Use Only (Optional)
Reviewed By: [Name]
Title / Role: [Adjuster / Claims Representative / Attorney / Staff]
Date of Review: [MM/DD/YYYY]
Internal Notes / Adjustments:
[Short internal notes, if used by an organization or insurer.]
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Learn more about
Medical Expense Summary Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
MEDICAL EXPENSE SUMMARY TEMPLATE FAQ
What is a Medical Expense Summary?
A Medical Expense Summary is a document that organizes all of your medical-related costs in one place. It typically lists providers, dates of service, types of treatment, and amounts billed or paid so that insurance companies, attorneys, or accountants can quickly see the total medical costs related to an accident, injury, or illness.
When should I use a Medical Expense Summary?
You can use a Medical Expense Summary when submitting an insurance claim, preparing for settlement negotiations in an injury case, organizing documents for a DUI-related crash, requesting reimbursement from an employer or health plan, or gathering records for tax or personal budgeting purposes. It helps show the full picture of what your medical care has cost.
What should I include in a Medical Expense Summary?
A helpful Medical Expense Summary usually includes: your identifying and case information, the time period covered, a breakdown of expenses by category (hospital, doctor visits, therapy, prescriptions, medical equipment, etc.), itemized entries for each bill or payment, the status of each item (paid, partially paid, or outstanding), and grand totals. It is also useful to note which expenses were covered by insurance and which you paid out of pocket.
Can I use this Medical Expense Summary for an insurance or legal claim?
Yes. This Medical Expense Summary Template is designed so you can present your medical costs in a clear, organized format for insurers, attorneys, mediators, or courts. You should still follow any specific instructions from your lawyer, insurance company, or health plan about how to submit bills, receipts, and supporting documents.
What documents should I attach to support my Medical Expense Summary?
You will usually want to attach copies of medical bills and statements, explanation of benefits (EOBs) from your health insurance, pharmacy receipts, invoices for therapy or counseling, receipts for medical equipment, and proof of any payments you made (such as credit card or bank records). Numbering each line item and writing that number on the matching bill can make review much easier.
Can AI Lawyer help me prepare my Medical Expense Summary?
Yes. AI Lawyer can help you structure and format your Medical Expense Summary by suggesting categories, wording, and layout. You provide the actual dates, providers, and amounts, and AI Lawyer helps turn them into a clean, readable document you can review with your insurer, attorney, or tax professional. This template and any AI-generated text are for document organization only and are not legal, medical, or tax advice. For questions about coverage, claim value, or tax treatment of medical expenses, please consult a licensed professional.
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