Metro West Housing Solutions

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