MCBS Calendar ENG

Medical Planner

2019-2020

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 9
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

SEPTEMBER 2 0 1 9
Sunday

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:
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

2

Tuesday

3

Wednesday

4

Thursday

5

Friday

6

Saturday

7

Labor Day

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Grandparent’s Day

First Day of Autumn

29

Rosh Hashana
(Begins at sundown)

30

OCTOBER 2 0 1 9
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

6

Tuesday

1

2

Thursday

3

Friday

4

Saturday

5

8

9

10

11

12

15

16

17

18

19

25

26

7

Columbus Day

Wednesday

Yom Kippur
(Begins at sundown)

13

14

20

21

22

23

24

27

28

29

31
30

31

Halloween

NOVEMBER 2 0 1 9
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

1

Saturday

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

30

Daylight Saving
Time ends

Veterans Day

Thanksgiving Day

DECEMBER 2 0 1 9
Sunday

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:
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

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

First day of Winter

22

23

24

Hanukkah
(Begins at sundown)

29

25

Christmas Day

30

31

26

27

28

JANUARY 2 0 2 0
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

1

Thursday

2

Friday

3

Saturday

4

New Year’s Day

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

27

28

29

30
31

Martin Luther
King, Jr. Day

26

FEBRUARY 2 0 2 0
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

Valentine’s Day

16

17

18

19

20

21

22

24

25

26

27

28

29

Presidents’ Day

23

MARCH 2 0 2 0
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:

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

26

27

28

Daylight Saving
Time starts

First day of Spring

St. Patrick’s Day

22

23

24

29

30

31

25

APRIL 2 0 2 0
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:

Tuesday

Wednesday

1

Thursday

2

Friday

3

Saturday

4

April Fool’s Day

5

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

6

7

12

13

14

19

20

26

27

8

Passover
(Begins at sundown)

9

10

11

Good Friday

15

16

17

18

21

22

23

24

25

28
30

29

30

Easter Sunday

MAY 2 0 2 0
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

1

Saturday

2

3

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
31

30

Mothers’ Day

Memorial Day

JUNE 2 0 2 0
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:

Flag Day

Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:

Fathers’ Day

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

First day of Summer

21

22

23

28

29

30

24

25

26

27

JULY 2 0 2 0
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

1

Thursday

2

Friday

3

Saturday

4

Independence Day

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
31

30

31

AUGUST 2 0 2 0
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 2 0
Sunday

Monday

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:

Tuesday

1

Wednesday

2

Thursday

3

Friday

4

Saturday

5

7

8

9

10

11

12

14

15

16

17

18

19

Labor Day

13

Rosh Hashana
(Begins at sundown)

Grandparents Day

20

21

22

23

First day of Autumn

27

Yom Kippur
(Begins at sundown)

28

29

30

24

25

26

OCTOBER 2 0 2 0
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 2 0
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:

1

Monday

2

Tuesday

3

Wednesday

4

Thursday

5

Friday

6

Saturday

7

Daylight Saving
Time ends

8

9

10

11

12

13

14

Veterans Day

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Thanksgiving Day

29

30

DECEMBER 2 0 2 0
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

6

Tuesday

7

1

8

Wednesday

2

9

Thursday

3

Friday

10

4

Saturday

5

11

12

Hanukkah
(Begins at sundown)

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

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 09/30/2021.