Docstoc

medexp

Document Sample
medexp Powered By Docstoc
					&PN
&CAB


&SD


&VCN
&VAB


Dear &VCN:

&VTN has applied for housing assistance under a program of the U. S. Department of
Housing and Urban Development (HUD). HUD requires the housing owner to verify all
information that is used in determining this person’s eligibility or level of benefits.

We ask your cooperation in providing the following information and returning it to the
person listed at the top of this letter. Your prompt return of this information will help to
assure timely processing of the application for assistance. Enclosed is a self-addressed
stamped envelope for this purpose. The applicant/tenant has consented to this release of
information as shown below.

Complete the statement that provides the most accurate information in each category:

       1. The person whose signature appears on this form paid $_________ for medical expenses for
          the previous 12 months from ___/___/_____ to ___/___/_____
          EXCLUDE ONE-TIME EXPENSES THAT ARE NOT EXPECTED TO
          REOCCUR AND AMOUNTS THAT WILL BE REIMUBRSED BY
          INSURANCE OR A GOVERNMENT AGENCY

         OR

       2. The person whose signature appears on this form is expected to pay approximately
          $_________ in medical expenses for the following 12 months from ___/___/_____ to
          ___/___/_____
         EXCLUDE ONE-TIME EXPENSES THAT ARE NOT EXPECTED TO
         REOCCUR AND AMOUNTS THAT WILL BE REIMUBRSED BY
         INSURANCE OR A GOVERNMENT AGENCY
EXAMPLES OF MEDICAL EXPENSES INCLUDE (Please check expenses included in this
estimate)

            Services of physicians and other health care professionals.

            Services of health care facilities.

            Prescriptions/non-prescription medicines

            Dental expenses

            Eyeglasses, hearing aids, batteries, wheelchair, walker and other supplies and
            equipment.

            Attendant care or periodic medical care.

            Other (specify general category): ____________________________



Name and Title of Person Supplying the Information (Print)




Organization:




Signature:




RELEASE: I hereby authorize the release of the required information. Information
obtained under this consent is limited to information that is no older than 12 months.
There are circumstances which would require the owner to verify information that is up to
5 years old, which would be authorized by me on a separate consent attached to a copy of
this consent.


______________________________________________________________________
Signature                                                        Date

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:3/29/2012
language:
pages:2
molly.snider molly.snider
About