Financial Aid Office

Medical/Dental Expense Request — Form

1. Student Info (required)

First Name:

Last Name:

Email:

Phone:

2. Expenses (required)

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

1. Description of Expense

1. Date of Service

1. Amount

2. Description of Expense

2. Date of Service

2. Amount

3. Description of Expense

3. Date of Service

3. Amount

4. Description of Expense

4. Date of Service

4. Amount

5. Description of Expense

5. Date of Service

5. Amount

6. Description of Expense

6. Date of Service

6. Amount

7. Description of Expense

7. Date of Service

7. Amount

8. Description of Expense

8. Date of Service

8. Amount

9. Description of Expense

9. Date of Service

9. Amount

10. Description of Expense

10. Date of Service

10. Amount

Total Amount

3. Additional Information (optional)

Provide any additional information or comments regarding your request:

4. Confirm & Upload Documents (required)

Consent

By submitting this financial aid application and uploading documents, I hereby consent to Stanford University’s collection and processing of any sensitive personal data contained in my application and documents to evaluate my application for the other purposes described in Stanford University’s Online Privacy, Offline Privacy Policy, and the Privacy Notice for Admissions and Financial Aid which can be found at privacy.stanford.edu

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.

Student ID:

Today's Date:

Form version:

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Financial Aid Office

Medical/Dental Expense Request — Form

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