"Medical Expenses Worksheet"

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Tax Payer
Spouse
For clients age 63 as of December 31, 2016
Medical Expenses
Taxpayer
Spouse
Insurance Premiums medical, dental & vision
Medicare Insurance
Long Term Care Premiums
Prescriptions
Doctors
Dentists
Eyeglasses and Contact Lenses
Hospitals
Nursing Home
In Home Care
Hearing Aids and Batteries
Chiropractors
Other _____________
Other _____________
Other _____________
Total Medical Expense
-
-
Medical Miles
Please provide your medical expense for each category above. We do not need
receipts, please keep the receipts for your records.
Tax Payer
Spouse
For clients age 63 as of December 31, 2016
Medical Expenses
Taxpayer
Spouse
Insurance Premiums medical, dental & vision
Medicare Insurance
Long Term Care Premiums
Prescriptions
Doctors
Dentists
Eyeglasses and Contact Lenses
Hospitals
Nursing Home
In Home Care
Hearing Aids and Batteries
Chiropractors
Other _____________
Other _____________
Other _____________
Total Medical Expense
-
-
Medical Miles
Please provide your medical expense for each category above. We do not need
receipts, please keep the receipts for your records.