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Utah medical expenses worksheet

Use this worksheet to track your medical visits and the associated expenses. Make sure to include medical treatments with doctors, chiroprac- tors, physical therapists, alternative practitioners, medical exams, MRI or other scans, or any other medical appointments. If possible, ask your doctors to opine regarding your future prognosis and to estimate your future medical needs and the associated costs. Document all of your out-of-pocket expenses in connection with your medical treatments.

Name of Provider/Facility Date of Treatment Description of Services Amount Owed Amount Paid

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