UNREIMBURSED MEDICAL EXPENSE FORM YEAR__________________________ PLAINTIFF_______________________ DEFENDANT_____________________ CASE #________________ DEPENDENT FOR WHOM EXPENSES INCURRED _______________________________ (only one per page) Plaintiff’s share of unreimbursed expenses Defendant’s share of unreimbursed expenses Medical Service Date Type of Service ____________% ____________% Total Bill Insurance Total Amount Reimbursement Balance Amount Plaintiff signature___________________________ Plaintiff Defendant Defendant Balance Date Paid Paid & Payable to Whom Defendant Received Bill Date__________________ EN-024 American LegalNet, Inc. www.FormsWorkflow.com