
Verification of Medical Expenses
TO WHOM IT MAY CONCERN:
The applicant/participant is applying for housing assistance subsidized through the Department of Housing and Urban Development. Federal regulations require that all income, expenses, preferences and other information related to eligibility must be third-party verified. Please complete this form as it applies to the above-named family member who is claiming preference. Be assured that your reply will be kept confidential. Please provide the requested information within the next ten days. If you have any questions, please contact:
________________________________________ at ___________________________________
Housing Specialist Telephone Number
RELEASE OF INFORMATION
I hereby authorize the release of the information requested below:
_______________________________________________ _______________________
Signature of Head of Household Date
_______________________________________________ _______________________
Signature of Family Member (if adult) Date
EXPENSE TYPE:
☐ Physician Care
☐ Hospital/Clinic Care
☐ Dental Care
☐ Medical Insurance
☐ Prescriptions
☐ Eye/Vision Care
☐ Therapy
☐ Other
FREQUENCY OF EXPENSE:
☐ One time only
☐ Weekly
☐ Monthly
☐ Every two months
☐ Other
Cost per occurrence: $________ Amount paid out-of-pocket in last four months: $________
______________________________ _________________________ ______________________________
Signature of Verifying Party Printed Name Title of Verifying Party
_____________________________________ _____________________ __________ _______________
Street Address City State Zip Code
________________________ _________________________________ ____________________________
Telephone Number Email Address Date Signed
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL, FALSE STATEMENTS OF MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.
ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.
575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org
