ProBusiness--FSA/COBRA--Health Care Expense Worksheet

Health Care Expense Worksheet

The planning worksheet below can help you estimate your health care expenses not covered under your company's group insurance plan. Remember, all eligible expenses for you, your spouse and your eligible dependents are reimbursable from your Health Care Spending Account.

Medical Expenses
Copayments	$
Deductibles	$
Physical exams	$
Prescription drugs	$
Surgical fees	$
X-Ray/Lab fees	$
Other medical expenses	$
Vision Expenses
Contact lens supplies	$
Copayments	$
Deductibles	$
Eye examinations	$
Prescription contact lenses	$
Prescription eyeglasses or sunglasses	$
Dental Expenses
Copayments	$
Deductibles	$
Dentures	$
Examinations	$
Orthodontia	$
Restorative work (crowns, caps, bridges)	$
Teeth cleaning	$
Other dental expenses	$
Other Expenses
Acupuncture, chiropractors, naturopaths	$
Hearing aids	$
Immunization fees	$
Psychiatrist, psychologist, counseling*	$
* Allowed for treatment of specific physical or mental disorder (e.g., depression, alcohol or drug treatment). A diagnosis is necessary for reimbursement.

Total Expenses	$

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Last updated Tuesday, July 09, 2002 ©2007 ADP, Inc.	Privacy Statement Terms and Conditions