Specialty Work Sheet For Medical Expenses

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SPECIALTY WORK SHEET for MEDICAL EXPENSES
In order to maximize your deductions, please complete this form.
CLIENT
TAX YEAR
Note: These expenses must be paid by the taxpayer and for the taxpayer's self, spouse or dependent. Do not deduct expenses which are
reimbursed by insurance or other sources.
Medications and Drugs
Prescibed Controlled Substances
Other
Insulin
TOTAL MEDICATIONS AND DRUGS
$0.00
Doctors, Dentists, Psychiatrists, Chiropractors, C/S Practitioners, Acupuncture, Others
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
TOTAL DOCTORS AND DENTISTS
$0.00
Hospitals
TOTAL HOSPITAL EXPENSES
$0.00
Insurance
Health Insurance
Contact Insurance
Hospital Insurance
School Insurance
Group Insurance
Supplemental Medicare
Other Insurance
Other (Do not include income protect plans)
TOTAL INSURANCE PREMIUMS
$0.00
Other Medical and Dental Expenses
Anesthesia
X-rays
Oxygen
Clinics
Laboratories
Sanitariums
Nurses
Nurses Aides
Ambulance
Psychologists
Psychiatric Care
Physical Therapy
Mental Therapy
Eyeglasses
Optometrists
Contact Lenses
Hearing Aids
Hearing Aid Batteries
Prescribed Pools and Spas
Surgical Equipment
Hospital Equipment
Hospital Supplies
Orthopedic Shoes
Canes
Crutches
Braces
Elastic Hose
Massage Units
Heating Pads
Humidifiers
Capital Improvements (Amount not adding to FMV)
Asthmatic Air Conditioner
Elevator for Heart Patient
Wheel Chair
Wheel Chair Ramps
Repairs on Capital Improvements
Water Fluoridation Systems
Wigs
Prescribed Health Institutes, Gymnasium, Swin Clubs
Prescribed Exercise Equipment
Special Schools for the Handicapped
Long Distance Telephone to Schedule Appointments
Travel and Transportation Lodging ($50 max.)
Travel and Transporation Parking and Tolls
TOTAL OTHER MEDICAL AND DENTAL EXPENSES
$0.00
THE ABOVE EXPENSES ARE MEDICAL EXPENSES PAID FOR BY THE TAXPAYER.

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