I am recently divorced, and among the exhibits included in the judgement is a form that the other parent and I must fill out when requesting reimbursement from each other for medical costs. I looked around online because the copy I received is just a flattened page among many inside a lengthy PDF document. I found a few different versions, but none of them were fillable, so I created one. This will calculate your totals for each type of cost and then use the number you put into the Percentage field to calculate how much you are requesting from the other parent.
Please let me know in the comments if you find any issues. Also to note, I recreated the form, but did not fix any of the poor wording or grammar issues.