Medical Expense Form 2022-2023

Medical Expense Form
2022-2023 Academic Year

Please select the option that best identifies you.

Forms are available to enrolled and accepted students only. Please contact the Financial Aid Office at (570) 941-7701 or finaid@scranton.edu for additional information.

Student First Name

Student Last Name

Royal ID (R followed by 8 Numbers)

Student's Email Address (please enter the email used on your application)

University of Scranton Email Address

Provide the name of the parent who will be signing this form.

Parent First Name

Parent Last Name

Parent's Email Address

Daytime Phone Number

The purpose of this form is to report extraordinary medical expenses paid in calendar year 2021 for family members. Complete the worksheet below to determine if this form should be submitted.

Total amount of unreimbursed medical, dental and vision care expenses actually paid in 2021. Include paid insurance premiums. Do not include amounts covered by insurance, company medical reimbursement account (flexible spending account), or self-employed health deductions.

Adjusted Gross Income reported on 2021 Federal Tax Return

10% of Adjusted Gross Income

Unreimbursed expenses less 10% of Adjusted Gross Income

Because the amount of your unreimbursed medical expenses is less than 10% of your household's 2021 Adjusted Gross Income, it appears that you may not eligible for a professional judgement consideration. If you would still like your documentation reviewed, please proceed with this form and upload the required documentation as indicated below. If you have any questions, please contact the Financial Aid Office at (570) 941-7701 or finaid@scranton.edu.

If your unreimbursed medical expenses are greater than 10% of your Adjusted Gross Income as determined above, please attach a copy of your 1040 Schedule A from 2021. If the requested documents for 2021 are not submitted, your application will be considered incomplete, and the University of Scranton will be unable to give further consideration to your request.

Upon submission of this form, you will be immediately redirected to a signature page. Please print and sign the signature page and then upload a PDF as instructed.

Without the signature page, the Medical Expense Form will be considered incomplete

Admissions

Medical Expense Form 2022-2023

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