EFTA01222131.pdf

Schedule A Medical Expenses Worksheet 2017 Line 1 • Keep for your records Name(s) Shown on Return Social Security Number 1 Prescription medications 2 Health Insurance premiums: a Premiums other than self-employed health insurance or reported on a 1095-A . . . 2a b From Form(s) 1095-A - net of adjustments b Taxpayer's portion of 1095-A premiums (total less spouse) . . . Spouses portion of 1095-A premiums. enter the amount for the spouse, the remaining goes to the taxpayer c Medicare premiums d From Form(s) 1099-R d NOTE: If LTC premiums are associated with a specific business activity, enter them directly on the applicable Self-Employed Health and Long-Term Care Insurance Deduction Worksheet, not on lines 2e - 2j below. e Taxpayer's gross long-term care premiums 2e t Taxpayer's allowable long-term care premiums t g Spouses gross long-term care premiums 9 h Spouses allowable long-term care premiums h I Dep or child under 27 gross long-term care premiums . j Dep or child under 27 allowable long-term care prem. . k Total allowable long-term care premiums. sum of lines 2f, 2h, and 2j k I Taxpayer's long-term care premiums not deducted as an adjustment to income. . m Spouses long-term care premiums not deducted as an adjustment to income. . . m n Dependent's long-term care premiums not deducted as an adj to income n o Other self-employed health insurance not deducted as an adj to income 0 3 Fees for doctors, dentists. etc 4 Fees for hospitals, clinics, etc 4 5 Lab and x-ray fees 5 6 Expenses for qualified long-term care 6 7 Eyeglasses and contact lenses 7 8 Medical equipment and supplies 9 Medical transportation expenses: a Medical miles driven 9a b Multiply the number of miles on line 9a by 17 cents per mile c Other medical transportation costs not included above for example: ambulance fees d Total medical transportation expenses (add lines 9b and 9c) 9d 10 Lodging for medical purposes (up to $50 per night per person) 10 11 Other medical and dental expenses: a 11 a b b d d e e 9 9 h h J 12 Total of medical and dental expenses (add lines 1 through 11j) 12 13 a Less: insurance reimbursement for any expenses listed 13a b Less: medical savings account (MSA) or health savings account (HSA) distributions b 14 Total deductible medical and dental expenses. Subtract lines 13a plus 13b from line 12 (to Schedule A, line 1) 14 EFTA01222131