Log Of Incurred Medical Expenses
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2ATTACHMENT B
SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
Log of Incurred Medical Expenses
For the Month of _______________
A brief description of expenses which can be deducted, including the limits, is found on the back of this form.
Beneficiary's Name:
____________________________________________________________________
Medicaid ID Number:
____________________________________________________________________
Month:
____________________________________________________________________
__________________________________________________________________________________________
Lesser of
Date Bill
Amount
Cost or
Date
Provided
Billed for
Allowable
Item/Service
Rendered
to Facility
Item/Service
Deduction*
______________________________________
__________
_________
_________
________
______________________________________
__________
_________
_________
________
______________________________________
__________
__________
_________
________
______________________________________
__________
__________
_________
________
______________________________________
__________
__________
_________
________
Total
________________________
Monthly Recurring Income (SCDHHS Form 181)
______________________
Incurred Monthly Expenses
______________________
(Not to Exceed Monthly Recurring Income)
Amount carried over to next month**
______________________
*If actual cost is less than the limit found on the back of this form, enter actual cost. If actual cost is greater
than the limit, enter the limit amount.
**If incurred monthly expenses exceed monthly recurring income, the difference can be carried forward to the
next month. Put the difference on the first line of next month's log sheet. Include the statement "Prior Month
Carry Forward" in the item/service line and the amount to be carried forward in the "Lesser of Cost or
Allowable Deduction" column.
SCDHHS Form 236 (Rev. 06/08)
Page 1
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