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| Name of medicine or description of equipment/supplies (e.g., syringes, thermometer) | Amount paid by you | Provided by home care agency. If equipment, borrowed or given to you to keep? | |
|---|---|---|---|
| Total cost of medicine (including dispensing fee) or supplies/equipment (rented/purchased) | Will you be reimbursed for this money? (yes or no) If yes, indicate % or amount reimbursed |
||
| Acetaminophen | $10 | No | No |
| Nutritional Drinks | $13 | Yes (90%) | No |
