Explanation Of Health Care Expenses

EXPLANATION OF HEALTH CARE EXPENSES Name of Child _____________________(DOB: __________) Date of Treatment (Chronological order) TOTAL BILL Check box if bill attached Date bill sent to PLAINTIFF/ DEFENDANT Case No.:___________________ Submitted by: _____________________ Amount paid by insurance Check box if Explanation of Benefits attached Amount adjusted by provider Amount paid by PLAINTIFF Amount paid by DEFENDANT Amount due from UNPAID BALANCE PLAINTIFF/ DEFENDANT Name of Provider & nature of service provided (Circle one) (Circle one) TOTALS: Instructions 1. Use a separate sheet for each child and each year. 2. Attach all bills and all insurance Explanations of Benefits if available. 3. List each service provided in chronological order. Notes:________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ H898_TP.DOC (4/2007) American LegalNet, Inc. www.FormsWorkFlow.com H898_TP.DOC (4/2007) American LegalNet, Inc. www.FormsWorkFlow.com