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pdfMCBS
Medicare Current Beneficiary Survey
Medical Planner
2015-2016
A Message from
Thank you for participating in the Medicare Current Beneficiary
Survey (MCBS). With your help, we are working to make Medicare a
more cost-effective and more high-quality form of health insurance
that meets the needs of all beneficiaries. As a reminder, whether you
take part in the survey is entirely your choice. Your Medicare benefits
will not be affected by the answers that you give, or by whether or not
you participate. Also, your answers must be kept private and
confidential. The Federal Privacy Act of 1974 requires this.
William Long—Project Officer
A Message from
Your participation in the MCBS provides valuable information to
both researchers and policymakers about the needs of Americans who
have Medicare health insurance.
CMS collects large amounts of information about hospitals, doctors,
and other medical professionals. They can tell how Medicare works
for those groups, but the only way to learn about how the Medicare
program works for people like you is to ask. AARP supports this
survey because we think it is important. Please take part and help
improve your Medicare program.
How to Use Your Planner
We are providing this planner to help you organize your doctor visits,
possible hospital stays, and other health care-related events. This will
help you by providing you one place to keep track of all of these items,
both for planning purposes and when trying to recall events with your
interviewer. It will also help us ensure that the information we collect
is as accurate as possible. If the information we collect does not
accurately represent what is going on in your life, it will not be as
helpful at improving Medicare.
When using this planner, it is important to record the following types
of information in the appropriate date square:
• Doctor and dentist appointments
• When prescribed medicines are filled or re-filled
• The total cost of an event and what you paid
• Hospital visits, including to the emergency room or as an
outpatient
• Labs, x-rays, and other tests
• Nursing home stays
• Home health visits by a medical professional, family member, or
friend
• Eyeglasses, diabetic equipment, ambulance services, or other
medical items purchased
Important Contact Information
For questions or concerns about the survey you can contact MCBS
staff at NORC at the University of Chicago at any time.
Call toll-free at: 877-389-3429
Email at: [email protected]
Visit us at: www.mcbs.norc.org
If you have any questions or concerns about Medicare or your
government benefits in general, please refer to the information below:
Call the Medicare Hotline toll-free at: 800-633-4227
Call the Medicare Fraud Hotline toll-free at: 800-447-8477
Call the Social Security Administration toll-free at: 800-772-1213
Visit the Centers for Medicare and Medicare Services at:
www.cms.hhs.gov
Visit AARP at: www.aarp.org
MY MEDICAL ADDRESS BOOK
Doctor Name:_______________________________________________________________________
Doctor Name:_______________________________________________________________________
Practice Name:______________________________________________________________________
Practice Name:______________________________________________________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Address: __________________________________________________________________________
Address: __________________________________________________________________________
City:_______________________________________ State:______ Zip:_________________________
City:_______________________________________ State:______ Zip:_________________________
Notes:_____________________________________________________________________________
Notes:_____________________________________________________________________________
Doctor Name:_______________________________________________________________________
Doctor Name:_______________________________________________________________________
Practice Name:______________________________________________________________________
Practice Name:______________________________________________________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Address: __________________________________________________________________________
Address: __________________________________________________________________________
City:_______________________________________ State:______ Zip:_________________________
City:_______________________________________ State:______ Zip:_________________________
Notes:_____________________________________________________________________________
Notes:_____________________________________________________________________________
Doctor Name:_______________________________________________________________________
Doctor Name:_______________________________________________________________________
Practice Name:______________________________________________________________________
Practice Name:______________________________________________________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Address: __________________________________________________________________________
Address: __________________________________________________________________________
City:_______________________________________ State:______ Zip:_________________________
City:_______________________________________ State:______ Zip:_________________________
Notes:_____________________________________________________________________________
Notes:_____________________________________________________________________________
Doctor Name:_______________________________________________________________________
Doctor Name:_______________________________________________________________________
Practice Name:______________________________________________________________________
Practice Name:______________________________________________________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Type of Dr:_________________________ Phone: ( __________ ) ______________________________
Address: __________________________________________________________________________
Address: __________________________________________________________________________
City:_______________________________________ State:______ Zip:_________________________
City:_______________________________________ State:______ Zip:_________________________
Notes:_____________________________________________________________________________
Notes:_____________________________________________________________________________
AUGUST 2 0 1 5
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
2
Monday
3
Tuesday
4
Wednesday
5
Thursday
6
Friday
7
Saturday
1/8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
SEPTEMBER 2 0 1 5
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
6
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
1
Wednesday
2
Thursday
3
Friday
4
Saturday
5
7
8
9
10
11
12
14
15
16
17
18
19
21
22
23
24
25
26
Labor Day
13
Grandparents Day
20
27
First day of Rosh
Hashana
28
29
Yom Kippur
First Day of Autumn
30
OCTOBER 2 0 1 5
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
1
Friday
2
Saturday
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Columbus Day
Halloween
NOVEMBER 2 0 1 5
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Daylight Saving
Time ends
1
Monday
2
Tuesday
3
8
9
10
15
16
22
23
Wednesday
4
Thursday
5
Friday
6
Saturday
7
11
12
13
14
17
18
19
20
21
24
25
26
27
28
Veterans Day
Thanksgiving Day
29
30
DECEMBER 2 0 1 5
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
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Amount charged & paid:
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Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
6
Tuesday
7
1
Wednesday
2
Thursday
3
Friday
4
Saturday
5
8
9
10
11
12
First day of Hanukkah
13
14
15
16
17
18
19
20
21
22
23
24
25
26
First day of Winter
27
Christmas Day
28
29
30
31
JANUARY 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
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Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
Friday
1
Saturday
2
New Year’s Day
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
26
27
28
29
30
24/31
Martin Luther
King, Jr. Day
FEBRUARY 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
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Medicine(s) prescribed:
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Amount charged & paid:
Appointment time:
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Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
1
Tuesday
2
Wednesday
3
Thursday
4
Friday
5
Saturday
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Valentine’s Day
Presidents’ Day
MARCH 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
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Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
Daylight Saving
Time starts
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
First day of Spring
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Easter Sunday
Monday
Tuesday
1
Wednesday
2
Thursday
3
Friday
4
Saturday
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
St. Patrick’s Day
Good Friday
27
28
29
30
31
APRIL 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
Friday
1
Saturday
2
April Fool’s Day
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
First day of Passover
24
25
26
27
28
29
30
MAY 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
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Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
1
Monday
2
Tuesday
3
Wednesday
4
Thursday
5
Friday
6
Saturday
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Mothers’ Day
Memorial Day
JUNE 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
1
Thursday
2
Friday
3
Saturday
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
28
29
30
Flag Day
Fathers’ Day
First day of Summer
26
27
JULY 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
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Medicine(s) prescribed:
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Amount charged & paid:
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Medicine(s) prescribed:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
3
Tuesday
Wednesday
Thursday
Friday
1
Saturday
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24/31
25
26
27
28
29
30
Independence Day
AUGUST 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
1
Tuesday
2
Wednesday
3
Thursday
4
Friday
5
Saturday
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
SEPTEMBER 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
4
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Reason for visit:
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Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
1
Friday
2
Saturday
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Labor Day
Grandparents Day
First day of Autumn
25
26
27
28
29
30
OCTOBER 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
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Amount charged & paid:
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Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
2
9
Monday
First day of Rosh
Hashana
3
Tuesday
4
10
11
16
17
23
24
30
31
5
Thursday
6
Friday
7
Saturday
1/8
12
13
14
15
18
19
20
21
22
25
26
27
28
29
Columbus Day
Halloween
Wednesday
Yom Kippur
NOVEMBER 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Daylight Saving
Time ends
Monday
Tuesday
1
Wednesday
2
Thursday
3
6
7
8
9
10
13
14
15
16
20
21
22
23
Friday
4
Saturday
5
11
12
17
18
19
24
25
26
Veterans Day
Thanksgiving Day
27
28
29
30
31
DECEMBER 2 0 1 6
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
1
Friday
2
Saturday
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
28
29
30
31
First Day of Winter
25
First day of Hanukkah
Christmas Day
26
27
NOTES
NOTES
NOTES
Any other questions?
Please feel free to contact MCBS staff at NORC at the University of Chicago at any time.
Call toll-free at: 877-389-3429
Email at: [email protected]
Visit us at: www.mcbs.norc.org
MCBS
Medicare Current Beneficiary Survey
http://www.cms.gov/MCBS
This survey is authorized by section 1875 (42 USC 139511) of the Social Security Act and is conducted by NORC at the University of Chicago
for the U.S. Department of Health and Human Services. OMB control number for this information collection is 0938-0568, and expires 07/31/2017.
| File Type | application/pdf |
| File Modified | 2015-11-12 |
| File Created | 2015-06-15 |