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.]