Out-of-Pocket Medical Expense Tracker

Setup Patients & Categories

Currency Symbol:

Date of Service/Purchase:

Patient:

Healthcare Provider/Vendor:

Type/Category of Expense:

Description of Service/Item:

Amount Billed by Provider (Optional):

Amount Paid Out-of-Pocket:

Insurance Claim Submitted?

Date Claim Submitted:

Amount Reimbursed by Insurance:

Date Reimbursement Received:

Receipt/Reference # (Optional):

Notes (Optional):

Patient:

Category:

Month/Year:

Claim Status:

Date	Patient	Provider/Vendor	Category	Description	Billed	Paid OOP	Claim Sub.	Reimbursed	Net OOP	Receipt #	Notes	Actions

Report Period:

Custom Start:

Custom End:

Total Amount Billed: N/A

Total Paid Out-of-Pocket: N/A

Total Reimbursed by Insurance: N/A

Total Net Out-of-Pocket Medical Expenses: N/A

Patient Name	Total Net OOP Expenses

Category	Total Net OOP Expenses	Avg. Net OOP Cost

Total Claims Submitted: 0

Total Value of Submitted Claims (Paid OOP): N/A

Total Amount Awaiting Reimbursement: N/A

Total Successfully Reimbursed: N/A