Stanford University

Financial Aid Office

Medical/Dental Expense Request — Form

1. Student Info (required)
2. Expenses (required)

List all out-of-pocket medical/dental expenses per receipt. The date of service must be within +/- 9 months from today.

3. Additional Information (optional)
4. Confirm & Upload Documents (required)


Please review the following statements. If you agree to the terms listed, submit the form.

  • I have not been reimbursed nor will I seek reimbursement of the expenses listed above from any other sources.
  • I understand that if I attach a medical or dental treatment plan, that I must submit the actual receipt when services are provided.
  • I understand that I may be offered loan funds only to cover these expenses.
  • I understand that I may need to wait up to four weeks to receive a response for this request.

By entering my Stanford ID number below, I am certifying that all information in this application is accurate and complete to the best of my knowledge.