Phone: / Fax: / Phone: / Fax:
We are required to verify the anticipatedmedical expenses of qualified applicants/residents living in affordable housing funded by the U.S. Department of Housing and Urban Development (HUD) or the U.S. Department of Agriculture (USDA-RD). We will use the information gathered to calculate rent.We do not need or require information regarding the individual’s health condition. See below for examples of medical expenses covered.
To comply with the above requirement, we ask your cooperation in supplying the medical expense information requested below regarding the referenced applicant/resident. Information provided will remain confidential.Please complete and return this form as soon as possible. If you have any questions, please call the telephone number listed above.
Owner/Owner’s Agent Signature: / Date:
RE: Applicant/Resident: / Social Security Number:
Applicant/Resident: You do not have to sign this form if either the requesting organization (property name, address, and phone/fax) or the organization (company name, address, and phone/fax) supplying the information is left blank.
RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than twelve (12) months. There are circumstances which would require the Owner to verify information that is up to five (5) years old which would be authorized by me on a separate consent attached to a copy of this consent.
Applicant/Resident Signature: / Date:
Information Requested: We cannot accept photocopies of patient records for “HIPAA Privacy Rule” reasons.
Please complete the statements in sections 1, 2, 3, and 4 below as they relate to the Applicant/Resident or Dependent.
Examples of medical expensesinclude, but are not limited, to the following:
- Services of Physicians, Dentists, Chiropractors, and other Health Care professionals.
- Prescription medicines.
- Services of Health Care facilities, i.e. clinics.
- Medical equipment, i.e. walker, wheelchair, etc.
- Attendant care for periodic health services.
- Eyeglasses, hearing aids, batteries, and other supplies.
- Assistance animal and related care.
Please complete Section 1.Then please select and mark the relevant box below in Section 2 or Section 3 and enter the dollar amount of the medical expenses for the Applicant/Resident as indicated by that section.
1 / Number of “estimated” office visits per year:
(Needed for mileage deduction only, does not apply to Pharmacy visits.) / #
2 / The Applicant/Resident whose signature appears on this form has paid “out-of-pocket” medical expenses(not covered by insurance/agency) for a full 12 months prior to the signature date above. / $
3 / The Applicant/Residentwhose signature appears on this form is expected to pay“out-of-pocket” medical expenses(not covered by insurance/agency) projected forward for 12 months from the signature date above.
Warning: Section 1001 of Title 18, United State code provides: “Whoever, in any matter within any jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals or covers up… a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”
Printed name of person
supplying the information: / Printed title of person
supplying the information:
Signature: / Date: / Telephone:
Medial Expense Verification (01/12)Page 1 of 1 TC-36hr