"Spreadsheet Template for Medical Expenses"

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EXHIBIT
RE: __________________________
_______________
SPREADSHEET FOR MEDICAL EXPENSES GIVEN TO _____________________________
#
DATE OF
SERVICES PROVIDED
NAME OF CHILD
AMOUNT OF BILL NOT
AMOUNT
DATE SUBMITTED TO
AMOUNT
SUBTOTAL OWED BY
BILL
PAID BY INSURANCE
YOU
OBLIGOR
OBLIGOR
OBLIGOR
PD, IF ANY
PD
EXHIBIT
RE: __________________________
_______________
SPREADSHEET FOR MEDICAL EXPENSES GIVEN TO _____________________________
#
DATE OF
SERVICES PROVIDED
NAME OF CHILD
AMOUNT OF BILL NOT
AMOUNT
DATE SUBMITTED TO
AMOUNT
SUBTOTAL OWED BY
BILL
PAID BY INSURANCE
YOU
OBLIGOR
OBLIGOR
OBLIGOR
PD, IF ANY
PD
DATE OF
PLACE OF SERVICE
AMOUNT OF BILL NOT
AMOUNT
DATE SUBMITTED TO
AMOUNT
SUBTOTAL OWED BY
BILL
SERVICES PROVIDED
PAID BY INSURANCE
YOU
OBLIGOR
OBLIGOR
OBLIGOR
PD, IF ANY
PD
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