Dr 353 2026

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4.8 out of 5

84 votes

The document is a 'Statement of Health Care Expenses' that requires parents to list health care expenses for a child, detailing each expense with corresponding information such as service date, provider name, patient name, amounts charged and paid, and any outstanding balances. It also instructs parents to attach relevant documents like bills and insurance explanations, organized by a numbered chart.

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Click ‘Get Form’ to open the dr 353 in the editor.
Begin by entering your name as Parent A in the designated field at the top of the form. This identifies you as the individual filling out the statement.
In the chart provided, start listing each health care expense chronologically, beginning with the oldest. Fill in the date of service, name of provider, and patient’s name in their respective fields.
For each expense, input the amount charged by the provider and attach a copy of their bill. Ensure that you also document any payments made by you and attach proof of payment.
If applicable, include amounts covered by insurance companies and attach any Explanation of Benefits (EOB) documents for clarity.
At the bottom of each attached document, write and circle its corresponding number from your chart to maintain organization.
Finally, review all entries for accuracy before saving your completed form for submission or further processing.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (84 Votes)

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