RECORD OF MEDICAL EXPENSE APPLIED TO THE DEDUCTIBLE 1. CASEHEAD: 2. CASE ID: 3. CASE NO.: 4. CERTIFICATION PERIOD: FROM THRU 5. DED. Record medical expenses in the order in which they are incurred: AMOUNT 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. BU DATE OF DATE OF PROVIDER AMOUNT TPR CLIENT AMOUNT DED. VERIFICATION CHARGED MEMBER SERVICE LAST RESP APPLIED BALANCE PAYMENT TO DED. DMA-5036 (1/87)
RECORD OF MEDICAL EXPENSE APPLIED TO THE DEDUCTIBLE 1. CASEHEAD: 2. CASE ID: 3. CASE NO.: 4. CERTIFICATION PERIOD: FROM THRU Record medical expenses in the order in which they are incurred: 5. DED. AMOUNT 6. BU MEMBER 7. DATE OF SERVICE 8. DATE OF LAST PAYMENT 9. PROVIDER 10. AMOUNT CHARGED 11. TPR 12. CLIENT RESP 13. AMOUNT APPLIED TO DED. 14. DED. BALANCE 15. VERIFICATION DMA-5036 (1/87)
93.778-1b-2017.docx