Patient Monthly Expense Report – Fill the Gaps in Lung Cancer

PATIENT INFORMATION

Patient Full Name:

Clinical Trial Site:

Street Address:

Treating Physician:

City / State / ZIP:

Reporting Month / Year:

Email Address:

Prepaid Card Last 4 Digits:

Phone Number:

EXPENSE LOG

#	Date	Expense Category	Description / Notes	Receipt Attached	Amount ($)
TOTAL EXPENSES					$0.00

MILEAGE CALCULATOR
FTG Standard Rate ($/mile)	$0.21
Total Miles Driven This Month
Calculated Mileage Reimbursement	$0.00

PER DIEM TRACKER
FTG Maximum Daily Per Diem Rate	$92.00
Number of Travel Days
Calculated Per Diem Total	$0.00

EXPENSE SUMMARY

Expense Category	Subtotal ($)	Notes
Air Travel	$0.00
Hotel	$0.00
Ground Transportation	$0.00
Mileage Reimbursement	$0.00
Food Per Diem	$0.00
Other (Pre-Approved)	$0.00
GRAND TOTAL		$0.00
★ Maximum Eligible Amount: Contact FTG program coordinator for current benefit limits applicable to your trial.

CAREGIVER EXPENSES

Did a caregiver travel with you?

Yes No

Subtotal — Caregiver-Related Expenses Included Above ($)

CERTIFICATION

I certify that the expenses listed above are accurate, were incurred solely for clinical trial travel, and comply with the terms of my Patient Prepaid Travel Card Agreement with Fill the Gaps in Lung Cancer. I understand that false statements may result in card suspension and repayment obligations.

Patient Signature *

Sign with mouse or finger

Printed Name:

Date:

UPLOAD RECEIPTS

📎 Attach Receipt Files

You may upload multiple files (JPG, PNG, PDF). Max 10MB per file.

📋 SUBMISSION REMINDER
Please submit this report along with all receipts to Fill the Gaps in Lung Cancer by the 5th of the following month.

✓ Your expense report has been submitted successfully! FTG will review and follow up with you.