Download:
pdf |
pdfMedical Planner
2017-2018
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: 1-877-389-3429
Email at: [email protected]
Visit us at: 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: 1-800-633-4227
Call the Medicare Fraud Hotline toll-free at: 1-800-447-8477
Call the Social Security Administration toll-free at: 1-800-772-1213
Visit the Centers for Medicare & Medicaid Services at:
www.cms.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 7
Monday
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:
Tuesday
Wednesday
Thursday
Friday
Saturday
1
2
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
SEPTEMBER 2 0 1 7
Sunday
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
3
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
Friday
Saturday
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Labor Day
Grandparent’s Day
Rosh Hashana
(Begins at sundown)
24
25
26
27
First Day of Autumn
28
29
Yom Kippur
(Begins at sundown)
30
OCTOBER 2 0 1 7
Monday
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:
Tuesday
Wednesday
Thursday
Friday
Saturday
1
2
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 7
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
5
Tuesday
6
Wednesday
7
Thursday
Friday
Saturday
1
2
3
4
8
9
10
11
Daylight Saving
Time ends
Veterans Day
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Thanksgiving Day
26
27
28
29
30
DECEMBER 2 0 1 7
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
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
20
21
22
23
28
29
30
Hanukkah
(Begins at sundown)
17
18
19
First day of Winter
24/31
25
Christmas Day
26
27
JANUARY 2 0 1 8
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
Friday
Saturday
1
2
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
New Year’s Day
Martin Luther
King, Jr. Day
FEBRUARY 2 0 1 8
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
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
22
23
24
Valentine’s Day
18
19
20
21
26
27
28
Presidents’ Day
25
MARCH 2 0 1 8
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
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Daylight Saving
Time starts
St. Patrick’s Day
18
19
20
21
22
23
24
27
28
29
30
31
First day of Spring
25
26
Good Friday /
Passover
(Begins at sundown)
APRIL 2 0 1 8
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
Friday
Saturday
1
2
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
Easter Sunday
April Fool’s Day
MAY 2 0 1 8
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
Friday
Saturday
1
2
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
Mothers’ Day
Memorial Day
JUNE 2 0 1 8
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
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
21
22
23
29
30
Flag Day
17
18
19
20
Fathers’ Day
First day of Summer
24
25
26
27
28
JULY 2 0 1 8
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
1
Tuesday
2
Wednesday
3
Thursday
Friday
Saturday
4
5
6
7
Independence Day
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
AUGUST 2 0 1 8
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
Friday
Saturday
1
2
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
SEPTEMBER 2 0 1 8
Sunday
Monday
2
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Thursday
Friday
Saturday
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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:
Wednesday
1
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:
Tuesday
Labor Day
Rosh Hashana
(Begins at sundown)
/ Grandparents Day
Yom Kippur
(Begins at sundown)
23/30
24
25
First day of Autumn
26
27
28
29
OCTOBER 2 0 1 8
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
Friday
Saturday
1
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
7
Columbus Day
Halloween
NOVEMBER 2 0 1 8
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
Friday
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
29
30
Daylight Saving
Time ends
Veterans Day
Thanksgiving Day
25
26
27
28
DECEMBER 2 0 1 8
Sunday
Monday
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:
Wednesday
Thursday
Friday
Saturday
1
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:
Tuesday
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
28
29
Hanukkah
(Begins at sundown)
First Day of Winter
23/30
24/31
25
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: 1-877-389-3429
Email at: [email protected]
Visit us at: 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 06/30/2019.
| File Type | application/pdf |
| File Title | 2017 MCBS Calendar |
| Subject | Respondent material, Calendar, medical planner, English, MCBS |
| Author | NORC |
| File Modified | 2017-06-15 |
| File Created | 2017-06-09 |