/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/resources/,

/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/resources/HSA-Expense-Estimate-Worksheet.pdf

201610284

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UWMF,

Benefits,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWHC Open Enrollment,Health Savings Account (HSA),Resources

HSA Expense Estimate Worksheet

HSA Expense Estimate Worksheet - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWHC Open Enrollment, Health Savings Account (HSA), Resources





Actual Expenses
Last Year
Estimated Expenses
New Year

High-Deductible Health Plan
Expenses toward plan deductible
Prescriptions $ _______________ $ _______________
Physician visits $ _______________ $ _______________
Hospital $ _______________ $ _______________
Laboratory/testing $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Miscellaneous Health Expenses Not Covered by Insurance
Over-the-counter medication $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Dental Expenses
Dental visits $ _______________ $ _______________
Fillings $ _______________ $ _______________
Major work (root canals, crowns, dentures, etc.) $ _______________ $ _______________
Orthodontia (braces) $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Vision Expenses
Eye examination $ _______________ $ _______________
Eyeglasses $ _______________ $ _______________
Contact lenses and solution $ _______________ $ _______________
LASIK surgery $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Hearing Expenses
Hearing examination $ _______________ $ _______________
Hearing aid $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Miscellaneous Dental, Vision, and Hearing Expenses Not Covered by Insurance
Over-the-counter medication $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Additional Contribution to Maximize Annual Savings
$ _______________ $ _______________

Total Annual Amounts: $ _______________ $ _______________



TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com


HEALTH SAVINGS ACCOUNT
ANNUAL EXPENSE ESTIMATE WORKSHEET