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pdfMedical Planner
2021-2022
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: 1-844-777-2151
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 2 1
Sunday
Appointment time:
1
Monday
2
Tuesday
3
Wednesday
4
Thursday
5
Friday
6
Saturday
7
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:
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 1
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:
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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:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
5
Monday
Tuesday
6
Wednesday
7
1
8
Thursday
2
9
Friday
3
10
Labor Day/
Rosh Hashana
(Begins at sundown)
12
13
14
15
11
16
17
18
23
24
25
Yom Kippur
(Begins at sundown)
20
21
22
First Day of Autumn
26
4
Patriot Day
Grandparent’s Day
19
Saturday
27
28
29
30
OCTOBER 2 0 2 1
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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Amount charged & paid:
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Doctor(s) seen:
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Medicine(s) prescribed:
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Amount charged & paid:
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
29
30
Columbu
Columbus
umbus
s Day
D
Da
ay
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Monday
31
Hall
Halloween
llo
owe
wee
en
NOVEMBER 2 0 2 1
Sunday
Appointment time:
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Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
7
Monday
1
8
Tuesday
2
9
Wednesday
3
Thursday
10
Daylight Saving
Time ends
4
Friday
5
Saturday
6
11
12
13
Veterans Day
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Thanksgiving Day
28
Hanukkah
(Begins at sundown)
29
30
DECEMBER 2 0 2 1
Sunday
Appointment time:
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Medicine(s) prescribed:
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Amount charged & paid:
Appointment time:
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Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
1
Thursday
2
3
Saturday
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
First day of Winter
26
Kwanzaa Begins
Friday
27
Christmas Day
Christmas Eve
28
29
30
31
New Years Eve
JA NUA RY 2 0 2 2
Sunday
Appointment time:
Doctor(s) seen:
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Amount charged & paid:
Appointment time:
Doctor(s) seen:
Reason for visit:
Medicine(s) prescribed:
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Amount charged & paid:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1
New Year’s Day
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
Martin Luther
King Jr. Day
FEBRUA RY 2 0 2 2
Sunday
Monday
Tuesday
Appointment time:
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Medicine(s) prescribed:
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Amount charged & paid:
1
Wednesday
2
Thursday
3
Friday
4
Saturday
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
22
23
24
25
26
Valentine’s Day
20
President’s Day
27
28
MARCH 2 0 2 2
Sunday
Monday
Appointment time:
Doctor(s) seen:
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Medicine(s) prescribed:
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Amount charged & paid:
1
Wednesday
2
Thursday
3
Friday
4
Saturday
5
Ash Wednesday
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Daylight Saving
Time starts
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First day of Spring
Appointment time:
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Tuesday
6
7
8
9
10
11
12
13
14
15
16
17
18
19
25
26
Purim
(Begins at sundown)
20
27
St. Patrick’s Day
21
22
23
24
28
29
30
31
APRIL 2 0 2 2
Sunday
Appointment time:
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Wednesday
Tuesday
Thursday
Friday
1
Appointment time:
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Amount charged & paid:
Psalm Sunday
Appointment time:
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Easter Sunday
Saturday
2
Ramadan
(Begins at sundown)
April Fool’s Day
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Monday
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Passover Begins/
Good Friday
17
18
19
20
21
22
23
24
25
26
27
28
29
30
M AY 2 0 2 2
Sunday
Appointment time:
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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:
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
Mother’s Day
Memorial Day
JUNE 2 0 2 2
Sunday
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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
21
22
23
24
25
29
30
Flag Day
19
20
Juneteenth/
Father’s Day
First Day of Summer
26
27
28
J U LY 2 0 2 2
Sunday
Appointment time:
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Tuesday
3
Appointment time:
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Monday
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
25
26
27
28
29
30
Independence Day
Eid al-Adha
31
AUGUST 2 0 2 2
Sunday
Appointment time:
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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 2 2
Sunday
Appointment time:
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Amount charged & paid:
4
Appointment time:
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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
Patriot Day/
Grandparents Day
First day of Autumn
25
Rosh Hashanah
(Begins at sundown)
26
27
28
29
30
OCTOBER 2 0 2 2
Sunday
Appointment time:
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Amount charged & paid:
Monday
2
Tuesday
3
Wednesday
4
Thursday
Friday
Saturday
1
5
6
7
8
Yom Kippur
(Begins at sundown)
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Columbus Day
30
Halloween
31
N O V E M B E R 202 2
Sunday
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Amount charged & paid:
6
Daylight Saving
Time ends
Monday
Tuesday
7
1
8
Wednesday
2
9
Thursday
3
Friday
10
4
Saturday
5
11
12
Veterans Day
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Thanksgiving Day
27
28
29
30
DECEMBER 2 0 2 2
Sunday
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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
Appointment time:
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Amount charged & paid:
Hanukkah (Begins
at sundown)
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Amount charged & paid:
Christmas Day
Christmas Eve
First Day of Winter
25
26
Kwanzaa Begins
27
28
29
30
31
New Years Eve
JA NUA RY 2 0 2 3
Sunday
Appointment time:
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Amount charged & paid:
New Year’s Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
2
3
4
5
16
38
49
105
11
6
12
7
13
8
149
15
10
16
11
17
12
18
13
19
14
20
15
21
16
22
17
18
23
19
24
20
25
21
26
27
22
28
23
29
24
25
30
26
31
26
27
28
27
30
29
28
1
72
Daylight Saving
Time ends
Martin Luther
King Jr.Day
Day
Veterans
30
Thanksgiving Day
FEBRUA RY 2 0 2 3
Sunday
Appointment time:
Doctor(s) seen:
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Medicine(s) prescribed:
Other items purchased:
Amount charged & paid:
Monday
Tuesday
Wednesday
11
Thursday
22
99
Friday
33
55
66
77
88
12
12
13
13
14
14
15
15
16
16
17
17
21
21
22
22
23
23
24
24
10
10
Saturday
44
11
11
18
18
Valentine’s Day
19
19
20
20
President’s Day
26
26
Ash Wednesday
27
27
28
28
25
25
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: 1-844-777-2151
Email at: [email protected]
Visit us at: mcbs.norc.org
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 02/29/2024.
| File Type | application/pdf |
| File Title | MCBS Calendar |
| Subject | MCBS, Respondent Material, Community, English |
| Author | NORC |
| File Modified | 2021-12-06 |
| File Created | 2021-06-10 |