Medical Expense Appeal Form for Returning Students

Complete this form to report excessive medical, dental, and vision care expenses your family paid during calendar year 2022. You must have completed a 2023-24 FAFSA before submitting this form. Please refer to your Self-Service Portal to confirm receipt of your applications and other required documents.

Appeal Information

*Denotes a required field.

Loyola Student ID*

Student First Name*

Student Last Name*

Student Phone Number*

Student Loyola Email Address*

Parent Name*

Parent Phone Number*

Parent Email Address*

Additional Appeal Information

Have you submitted your 2023-24 FAFSA?*

Yes

You will need to submit your 2023-24 FAFSA before you can submit this form. Please refer to your Self-Service Portal to confirm receipt of your 2023-24 FAFSA.

Medical, Dental and Vision Care Expenses

1. Total amount paid in 2022 for unreimbursed medical, dental, and vision care expenses. Do include your paid insurance premiums. Do NOT include amounts paid or covered by insurance, company medical reimbursement account, i.e., flexible spending, or self-employed health benefits.*

2. Enter the Adjusted Gross Income figure reported on your 2022 federal tax return*

3. Adjusted Gross Income x 11%

4. Total medical, dental, and vision care expenses that will be considered in your appeal (Line 1 minus Line 3)

Based on the information that was provided, you are not eligible to be considered for a medical expense appeal. Please refer to our policy page for additional appeal options.

Additional Information

Please provide any additional details of your family's medical expenses:*

Required Documentation and Instructions

Please submit the following documentation to financialaid@loyola.edu. Include your student ID and student name on all documents and Medical Expense Documents in your email subject line.

Signed 2022 federal 1040 tax return and all schedules, 2022 W2 form(s), if not already submitted.
Signed 2021 federal 1040 tax return and all schedules, 2021 W2 form(s), if not already submitted. Verify receipt through your Self-Service Portal
Signed 2023-2024 Dependent Verification Worksheet if not already submitted. Verify receipt through your Self-Service Portal
You may be required to provide additional documentation. If so, you will be notified via email.

Student and Parent Certification

I certify that the information submitted for this appeal is true and complete to the best of my knowledge. I agree to provide all support documentation required. I understand that failure to comply may result in the cancellation of this appeal. I further understand that if I have provided information in previous appeals, this may be reviewed for accuracy and it may impact the outcome of this and/or any future appeal. I understand that submission of this appeal does not guarantee an increase in financial aid. I understand if any assistance is provided in response to this appeal it is for the 2023-2024 academic year. I understand future consideration requires annual completion of the Loyola financial aid application process, need-based aid eligibility, and the availability of funds.

Electronic Student Signature*

Date*

Electronic Parent Signature*

Date*