Form M106 - Health Expenses - Claim For Relief Page 2

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Routine Health Expenses
(See Notes)
PPS No.
n
£
Maintenance or treatment in an approved nursing home
(1)
Nursing Home
Name and Address
n
£
Non-Routine Dental Treatment (per Med 2) (See “Receipts” section at top of Page 4)
(2)
£
(a) Services of a doctor/consultant
(b) Drugs/Medicines
(where prescribed by a doctor or other qualifying practitioner)
£
Total outlay on prescribed drugs/medicines for the year
(c) Educational Psychological Assessment
£
for a dependent child (see note overleaf)
(d) Speech and Language Therapy for a
£
dependent child (see note overleaf)
£
(e) Orthoptic or similar treatment
£
(f) Diagnostic procedures (X-rays, etc.)
£
(g) Physiotherapy or similar treatment
£
(h) Expenses incurred on any medical, surgical
or nursing appliance
£
(i) Maintenance or treatment in a hospital
£
(j) Other Qualifying Expenses
(provide brief details below)
£
Total
(a) to (j)
(3)
£
TOTAL HEALTH EXPENSES
(1 + 2 + 3)
Deductions
- (If none write "NONE")
Sums received or receivable in respect of any of the above expenses
£
(i)
from any public or local authority e.g. Health Service Executive
£
(ii) under any policy of insurance e.g. VHI, BUPA, VIVAS Health, etc.
£
(iii) other e.g. compensation claim
First £125 / £250 in this tax year (delete whichever is not applicable)
£125 / £250
If this claim refers to health expenses for one person deduct £125
l
If this claim refers to two or more people deduct £250
l
TOTAL DEDUCTIONS
£
AMOUNT ON WHICH TAX RELIEF IS CLAIMED
£
(Total Health Expenses less Total Deductions)
Page 2

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