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Published by Sourcebooks • P.O. Box 4410, Naperville, Illinois 60567-4410 • (630) 961-3900 • sourcebooks.com Printed and bound in the United States of America. VP 10 9 8 7 6 5 4 3 2 1
MEDICAL MY JORNAL
a Practical Guide with Tips & Tricks for Navigating the Medical Field & Logging Your Personal Treatment Plan
INTRODUCTION
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The information you collect can impact the quality of care you receive and help reduce the financial burden of your medical care. Sometimes medical providers may not record information accurately and the records you keep may have a big impact on your treatment and care.
• U se this journal to record all information on your medical care.
• Take the journal to all appointments and hospital stays.
• Ask questions and demand answers and explanations for anything you do not fully understand.
• Take another adult along to any visit to be the second set of ears.
• Basic Information to record in this journal
• Contact information for each doctor or caregiver
• Current list of medications
• List of any allergies
• Type and date of past surgeries, hospitalizations, and medical procedures
• Record of each office or hospital visit
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Insurance Information Copy and attach your insurance card here. Deductible $ Co-pay information º PPO º HMO º Medicare º Medicaid In-network % Out of network % Referral needed for specialist? º Yes º No Approval needed before procedure? º Yes º No Provider Toll Free Phone 8
Copy and attach your Medicare/Medicaid information on this page.
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QUESTIONS TO ASK
When choosing a doctor
QUESTIONS TO ASK
• Is my insurance accepted?
• What is “in- network” or “out- of- network” for my insurance?
• Labs they use?
• Affiliated hospital?
• Physical Therapy/Occupational Therapy?
• Referrals to other doctors?
• Is the practice owned by a hospital or licensed as a surgery center or independent practice? (Can lead to higher fees) Are “facility fees” or “visit fees” charged?
• Is there an APRN (Advanced Practice Registered Nurse), PA (Physician Assistant) or RN (Registered Nurse) available to answer questions?
• Are there lower charges for visits without doctor’s interaction?
• What is their off- hours or on- call coverage?
• Are questions via phone or email accepted? Is there a charge? What is the normal response time?
• To what ER and/or hospital do they have admitting privileges?
Always check with your insurance provider before treatments. Make sure all referrals are “in-network”.
If you are not able to afford medical care, see the Negotiating Medical Bills section of this journal for information on applying for charity care through the provider.
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When visiting a doctor’s office
• Q uestions to ask about tests, procedures & surgeries
• Why is this being ordered?
• What results are expected?
• Will having this test change my treatment plan?
• What happens if we wait?
• What is the cost?
• Is a lower cost, less invasive alternative available?
• Does the doctor. have a financial stake in the lab or clinic being used?
• Questions to ask about medications & medical equipment
• What is the cost? Can equipment be rented? What will my insurance cover?
• Is there a less expensive formulation/alternative with similar results?
• What results should be expected? How long should it take to see results?
• What side effects could arise? What to do if they occur?
• Ask the doctor or caregiver to spell, define, or explain anything you don’t completely understand.
• W hat to record
• Vitals at each visit (weight, blood pressure, etc.)
• New treatments prescribed
• New medications or therapy, or changes to existing
• Answers to any of the above questions
Always check with your insurance provider with any questions about your coverage. Make sure all referrals are “in network”.
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In the hospital
• A t check- in
• Add “Consent is limited to in- network care only and excludes out- of- n etwork o fnetwork care” or “Did not read” to any document you sign concerning your consent of financial responsibility.
• Make sure you have a designated Power of Attorney.
• What is your status upon admission? (“Admitted” or “For observation”) What is the financial impact to you?
• During your stay
• Ask for names and purpose of any doctor visiting your room. (If there is no purpose, you can refuse their visit and not be charged.)
• What meds or treatments are they giving and why?
• At discharge
• Be sure the discharge orders are appropriate for your home situation.
• Will home care be needed? (Visiting Nurse, Home Care Aide, Therapist)
How often and for how long?
Can any of these services be out- p atient instead?
What is the cost? Covered by insurance?
• Is any specialized equipment needed?
What type?
When will it be delivered?
Have I received instructions for use?
What will it cost? Covered by insurance?
Do not accept any equipment you do not need or that can be inexpensively purchased or borrowed elsewhere. (i.e. wheelchairs, crutches, walkers) Local churches often have these items to loan.
• U nder the Affordable Care Act, nonprofit hospitals are required to provide free or discounted care to patients or risk losing their tax- exempt status. Get contact information for the billing office
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and information on payment options for your financial situation. Request forms and procedure for charity care, if needed.
Always check with your insurance provider with any questions about your coverage.
Make sure all referrals are “in-network”.
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Before going to the pharmacy
CHECK ONLINE WEBSITES TO COMPARE PRICES AND FIND THE LEAST EXPENSIVE LOCAL PHARMACY.
• G oodrx.com
• Needymeds.org
• S inglecare.com
At the pharmacy
• D oes the pharmacist know my all current meds, including over the counter medications, supplements, and vitamins?
• Is insurance prior- approval required?
• Will my insurance cover & what is my co- pay for new Rx?
• Is there any interaction or contraindication with other Rx I am taking?
• What results should be expected? How long should it take to see results?
• What side effects could arise? What to do if they occur?
• Is there an over the counter option?
• I s there a less expensive formulation or generic?
• Will I need to appeal to my insurer for brand- name Rx? n ame
Always check with your insurance provider with any questions about your coverage. Make sure all referrals are “in-network”.
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Pharmacy Notes 17
PHYSICIAN INFORMATION
NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
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NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
NOTES
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NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
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NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
NOTES
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NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
24
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
NOTES
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NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
26
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
NOTES
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NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
28
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
29
NOTES
NOTES
NOTES
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
30
NOTES
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
Office Address Email Address Phone Number Doctor Name Specialty Assistant/PA Name Off-hours Coverage
NOTES
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PROBLEM SUMMARY LIST/ MEDICAL CONDITIONS
Copy and attach or list the summary of all medical conditions on these pages. This list can be obtained from your physician or from the patient portal from your provider.
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Copy and attach or list the summary of all medical conditions on these pages. This list can be obtained from your physician or from the patient portal from your provider.
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EVENT LOG
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
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Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
41
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
42
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
43
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
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Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
45
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
46
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
47
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
48
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
49
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
50
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
51
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
52
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
53
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
54
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
55
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
56
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
57
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
58
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
59
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
60
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
61
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
62
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
63
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
64
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
65
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
66
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
67
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
68
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
69
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
70
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
71
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
72
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
73
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
74
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
75
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
76
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
77
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
78
Follow-up
Date º Appointment º ER/Urgent Care º Fall/Accident º Hospital EVENT: Doctor Reason for Visit Vitals Weight Blood Pressure Notes
79
MEDICATION RECORD
Medication Name & Dose º With food Side Effects
Without food
Prescribed by AM MidDay PM Bedtime
Date Ended
º Without food AM MidDay PM Bedtime Date
Side Effects
Medication Name & Dose º With food
º
Prescribed by
Date Prescribed
PM Bedtime Date Ended
AM MidDay
Prescribed for
Date Prescribed º
Time to take effect (see results)
food
Prescribed for
Date Prescribed Prescribed by Medication Name & Dose º With
Ended
Time to take effect (see results)
Prescribed for
Side Effects
Without food
82
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Medication Name & Dose
º With food
Prescribed by
º Without food
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
AM MidDay PM Bedtime Date Ended
83
Medication Name & Dose º With food Side Effects
Without food
Prescribed by AM MidDay PM Bedtime
Date Ended
º Without food AM MidDay PM Bedtime Date
Side Effects
Medication Name & Dose
º With food
Prescribed by
º
Date Prescribed
PM Bedtime Date Ended
Prescribed for
Date Prescribed º
Time to take effect (see results)
food
Prescribed for
Date Prescribed Prescribed by Medication Name & Dose º With
Ended
Time to take effect (see results)
Prescribed for
AM MidDay
Side Effects
Without food
84
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Medication Name & Dose
º With food
Prescribed by
Date Prescribed
Prescribed for
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Side Effects º Without food AM MidDay PM Bedtime Date Ended
85
Medication Name & Dose º With food Side Effects
Without food
Prescribed by AM MidDay PM Bedtime
Date Ended
º Without food AM MidDay PM Bedtime Date
Side Effects
Medication Name & Dose
º With food
Prescribed by
º
Date Prescribed
PM Bedtime Date Ended
Prescribed for
Date Prescribed º
Time to take effect (see results)
food
Prescribed for
Date Prescribed Prescribed by Medication Name & Dose º With
Ended
Time to take effect (see results)
Prescribed for
AM MidDay
Side Effects
Without food
86
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Medication Name & Dose
º With food
Prescribed by
Date Prescribed
Prescribed for
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Side Effects º Without food AM MidDay PM Bedtime Date Ended
87
Time to take effect (see results)
Prescribed for
Time to take effect (see results)
Medication Name & Dose
Prescribed by
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
º
AM MidDay PM Bedtime
Prescribed for Date Prescribed Prescribed by Medication Name & Dose º With food Side Effects
Without food
Date Ended
food
º Without food AM MidDay PM Bedtime Date
Date Prescribed Prescribed by Medication Name & Dose º With
Side Effects
Ended
º With food
º
AM MidDay
Without food
PM Bedtime Date Ended
88
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Medication Name & Dose
º With food
Prescribed by
Date Prescribed
Prescribed for
Time to take effect (see results)
Medication Name & Dose
º With food
Prescribed by
º Without food AM MidDay PM Bedtime
Date Prescribed
Prescribed for
Side Effects
Time to take effect (see results)
Date Ended
Side Effects º Without food AM MidDay PM Bedtime Date Ended
89
SUPPLEMENTS, HERBALS,
ETC. Name Dose Date Started Date Ended 90
VITAMINS,
SUPPLEMENTS, HERBALS, VITAMINS, ETC. Name Dose Date Started Date Ended 91
ALLERGY RECORD
Allergic to
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for
Reaction
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Allergic to
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for Allergic to
Reaction
Generic Name
Prescribed for
Reaction
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THERAPY RECORD
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
98
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
99
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
100
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
101
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
102
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
103
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
104
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
105
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
106
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
Therapy Type
Prescribed by
Provider Frequency
Date Prescribed
Prescribed for
Side Effects to watch for
Date Ended
Time to take effect (see results)
107
SURGERY RECORD
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
110
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
111
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
112
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
113
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
114
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
Date
Surgery/Procedure
Doctor
Results/Notes
115
NEGOTIATING MEDICAL BILLS
How to Negotiate Medical Bills
Always keep meticulous records of each contact. For every call: the name of the representative you spoke with, the date of the conversation, what agreement was made, always get a direct call back number for that person. Getting a doctor, hospital, or other medical provider to discount or write down a bill, or to offer a payment plan, may not be as difficult as you think. Under the Affordable Care Act, nonprofit hospitals are required to have a Financial Assistance Policy (FAP) for patients who are unable to afford their care—or the hospital risks losing their tax- exempt status. This policy includes free or discounted care. The exemptions for FAPs are dictated by the IRS Section 501(r)(4).
Assistance varies by geographic area and by provider. Assistance can take the form of writingoff a bill, writing- down a bill, lump-sum payment, discount charity care, or payment plans. You can search “Name of hospital + financial assistance” to find out the policies and criteria for your specific facility.
Follow these steps to help improve the odds for a positive outcome.
BEFORE medical services have been provided - ste ps to
1. C ontact the billing office of the provider.
take
2. E xplain your financial situation (be honest and realistic about what you can afford to pay).
3. A sk about all assistance options available.
• Write- o ffs (the provider reduces the bill to $0)
• Write- d owns (the provider writes off a large portion of the bill)
• L ump sum discounts for paying the entire bill (20% is common, but you can ask for more)
• C onsider payment plans (be realistic about what you can afford monthly and set that amount before negotiating).
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Under the Affordable Care Act, non-profit hospitals are required to offer patient assistance programs
AFTER medical services have been provided - ste ps to take
1. Request an itemized bill.
2. M ake sure all the bills are accounted for before beginning the negotiation process.
3. W hen speaking with the billing department, ask that your bill be “ put on hold from collections ” and that your account status be updated to “ pending ”.
4. A sk about any hardship program or charity care that is available.
5. A pply first before paying— d o it soon. Sometimes there is a ninety- d ay limit.
Under the Affordable Care Act, non-profit hospitals are required to offer patient assistance programs
The Negotiation Process
1. Review the itemized bill.
• If y ou’re discharged in the morning (as most patients are), dispute if you’re charged with a full daily- r oom rate for the date you left the hospital.
• D ispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily- r oom charge, because they are “considered the cost of doing business.”
2. I f you are able to pay the bill on one lump-sum, request a discount.
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• Your doctor, hospital, clinic, or therapy provider may offer a pay-in-full discount.
• A d iscount is more likely with a collection service or vendor who has purchased the debt. NOTE: Having a bill sent to collections will impact your credit score. It is always best to avoid this happening.
• A 20% discount is common.
3. S how evidence of cheaper service.
• R efer to the Healthcare Bluebook to compare your charges with national averages.
• C heck the Medicare price at www.cms.gov.
• clearhealthcosts.com/useful- links/#US- Government- price- lists
• fairhealthconsumer.org/
• A sk about a payment plan.
• C alculate how much you can realistically afford to pay monthly before beginning negotiations.
• R equest no interest or very low interest be charged.
• Get details of the payment plan in writing.
• O nce a plan has been agreed upon, keep current on your payments. If you fall behind, the agreement may be voided.
• If y our situation changes and you are not able to make a payment, contact the billing office immediately to discuss options.
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