MEDICAL EXPENSE CLAIM FORM - Coughlin and Associates 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal details, including your full name, date of birth, and contact information. Ensure accuracy as this information is crucial for processing your claim.
3. Indicate if you have any other health benefits or services by selecting 'YES' or 'NO'. If 'YES', provide the necessary details about the other plan.
4. Complete the dependant section if you are claiming expenses for a spouse or children. Include their names, dates of birth, and relationship to you.
5. For drug expenses, attach original receipts that include the drug identification number (DIN) and specify the costs incurred.
6. Fill out vision care expenses by indicating whether it's a new prescription and attaching itemized receipts for lenses and frames.
7. In the Other Expenses section, detail any additional costs related to your claim and attach relevant receipts.
8. Finally, review all provided information for accuracy before signing and dating the form at the bottom.

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