Dental Diagnosis Worksheet by wfd75777


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									       Health Care Flexible Spending Account Estimated Expense Worksheet

Please enter the estimated dollar amount that you and/or your family expect to
spend for each item, your total will calculate at the bottom

          Medical Expenses                                                              Dental Expenses

Co-payments                                                                Co-payments
Deductibles                                                                Deductibles
Lab Fees                                                                   Dentures
Physical Exams                                                             Examinations
Physician Fees                                                             Orthodontia
Prescription Drugs                                                         Fillings, crowns, bridges, etc
X-rays                                                                     Teeth cleaning
                                                                           Other Dental

Total Medical                              $0.00                           Total Dental                                   $0.00

           Vision Expenses                                                               Other Expenses

Contact lens supplies                                                      Acupuncture
Co-payments                                                                Chiropractor
Deductibles                                                                Hearing Aids
Eye Exams                                                                  Immunization fees
Prescription Contact
Lenses                                                                     *Psychiatric counseling
                                                                           Other expenses
Prescription eyeglasses
or sunglasses

Total Vision                               $0.00                           Total Other                                    $0.00

Total Expenses                                    $0.00

This tool is intended to be used for estimation purposes only

*Allowed for treatment of specific physical or mental disorder (e.g., depression, alcohol or drug dependency). A diagnosis Is
necessary for reimbursement.

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