Flexible Spending Account
Employee’s Personal Worksheet
Below are listed many expenses you and your family may have that are not completely covered by
insurance. Estimate your health related expenses not paid by group insurance for the upcoming plan year
(12 months).
Section I
Medical Reimbursement Worksheet to estimate dollars which will be expended that are not
reimbursed by insurance.
Group Insurance Deductibles & Coinsurance $________________
Medicine & Drugs Prescribed by a Doctor $________________
Routine Physical for Self & Family $________________
Fees to Doctors, Hospitals $________________
Child Birth $________________
Chiropractor $________________
Vision or Hearing Care $________________
Dental Care Expense $________________
Orthopedic Expenses $________________
Other Medical Expenses
(Travel @ The Current IRS Approved rate) $________________
Total Cost Estimate for Plan Year (12 months) $________________
Enter appropriate amount
Divide the estimated Plan Year total by 24 pay periods. $________________
Sections II
Department Care Reimbursement Worksheet
Child Care $________________
Nursing Home/Elder Care $________________
Total Cost Estimate for Plan Year (12 months) $__________________
Enter appropriate amount
Divide the estimated Plan Year total by 24 pay period. $_________________
