Advanced Benefit Strategies, Inc. Your Flexible Benefit Specialists

Medical/Dental/Vision Worksheet Estimate Form

Use this worksheet to estimate your “out-of-pocket” medical, dental and vision expenses for the coming year.

• You can include unreimbursed expenses for spouse and dependents.
• This is only a partial list from the “List of Eligible Expenses.” Read our “How to take full advantage of your ABS Flexible Benefit Plan”, or call ABS at (877) 732-8125.
• Focus on the kinds of expenses you and your families normally have or have scheduled for the upcoming year.
• Remember – you will not get a refund of unused money that remains in your account. It’s better to be slightly conservative when determining the total deduction amount.

Medical/Dental/Vision Expenses for yourself/family	Amount
Acupuncture	$
Chiropractic care	$
Contact lenses and solutions	$
Co-insurance	$
Co-payments for office visits	$
Co-payments for prescriptions	$
Deductibles	$
Dental care expenses (routine)	$
Dental care expenses (fillings/other services)	$
Eyeglasses and prescription sunglasses	$
Fitness club membership if necessary for medical reasons	$
Fitness equipment if necessary for medical reasons	$
Hearing Aids	$
Immunizations and inoculations	$
Infertility treatment including in-vitro fertilization	$
Laser eye surgery	$
Orthodontic expenses	$
Over the counter medicines and drugs	$
Psychiatric treatment/counseling	$
Other:	$
Total expenses:	$