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Forwarded message:
Subj: Cost of Parkinson's to society
Date: 95-06-19 16:07:01 EDT
From: ParkActNet
To: [log in to unmask]
The Parkinson's Action Network needs your help. We are developing data
showing
Parkinson's cost to society. We would like to ask that you spend a little
time and complete the following form and return it to us, either through
email or fax or regular mail. Feel free to give copies to your support group
or friends with Parkinson's. The more information we collect the better.
Thank you ahead of time for your help.
Note: If you think some element of costs has not been included or you have
other questions or comments, please let us know.
Name of Parkinson's-afflicted person:____________________________________
Address:____________________________ Phone:______________________
____________________________
____________________________
Age: ________________ Age of onset of Parkinson's symptoms:
__________
MEDICAL CARE COSTS [Totals per year, unless otherwise noted.]
1. Cost of medication per year:
Paid by you and not reimbursed: $______________________per
year
Paid or reimbursed by other source (for example,
Blue Cross, Kaiser, or Medicare): $______________________per year*
[If you don't know the amount, say so.]
Paid by whom: ___________________________________________________
Note: If medication was provided by your health care provider, etc. and
you don't
know the cost, note here what medication was
provided:______________________
__________________________________________________________________
2. Cost of medical care
Neurologists visits, other Parkinson's-related
medical procedures, treatments or other care)
paid by you and not reimbursed: $______________________per year
Neurologists visits, other Parkinson's-related
procedures, treatments or other care) paid or
reimbursed by a third party (for example,
Blue Cross, Kaiser or Medicare): $______________________per year*
Paid by whom:___________________________________________________
Note: If medical care was provided by your health care provider and you
don't know
the cost, note here what medical care per year was given (for example,
four
neurologists visits per year
etc.):_____________________________________________
________________________________________________________________
________________________________________________________________
* If you don't know the amount, indicate D/K.
3. Cost of related care:
Treatments necessitated by Parkinson's symptoms
(physical therapy, etc.) paid by you and not
reimbursed: $______________________per
year
Treatments necessitated by Parkinson's symptoms
(physical therapy, etc.) paid by a third party (for
example, Blue Cross, Kaiser or Medicare): $______________________per
year*
Paid by whom:___________________________________________________
Note: If related care was provided and you don't know the cost, note
here what related
care per year were given (for example, three physical therapy sessions,
etc.):________
________________________________________________________________________
4. Other related costs (e.g., cost of travel and lodging for special
procedures, second
opinions, etc.)
Paid by you and not reimbursed:
$______________________per year
Related costs paid by a third party
(Blue Cross, Kaiser or Medicare): $______________________per year*
Paid by whom: __________________________________________________
Note: If related costs were provided and you don't know the cost, note
here what
related costs per year were incurred (for example, airfare, lodging,
etc.):___________
________________________________________________________________________
Notes (elaborate here on any of the
above):__________________________________________
______________________________________________________________________________
______________________________________________________________________________
* If you don't know the amount, indicate D/K.
COST OF CARE FOR PARKINSON'S-AFFLICTED PERSON:
[If payment was made to another person for assisted living, a nursing home
or other care for
a person with disabled by Parkinoson's, please fill in this section.]
1. Assisted Living (e.g., in-home assistance with daily living, such as
dressing, eating, bathing
etc.) (Here specify the care
given):__________________________________________________
______________________________________________________________________________
__
Amount paid by you/your family and not reimbursed:
$_______________________per year
Amount paid or reimbursed by a third party, like a government agency,
charity, etc.:
$_______________________per year*, paid by: ___________________________
Note: If care was provided but you don't know the cost, describe the
care given:
___________________________________________________________________
___________________________________________________________________
2. Nursing home or equivalent care:
Amount paid by you/your family for a nursing home or equivalent, and not
reimbursed:
$_______________________per year
Amount paid by a third party like a government agency, disability
insurance plan, charity
etc.):
$________________________per year*, paid by:__________________
Note: If care was provided but you don't know the cost, describe the
care given:
____________________________________________________________________
____________________________________________________________________
Notes (elaborate here on any of the above)
______________________________________
___________________________________________________________________________
* If you don't know the amount, indicate D/K.
LOST WAGES/LOST PRODUCTIVITY
1. Wages/productivity lost by Parkinson's-afflicted person: If younger than
65, were work hours
or responsibilities cut, early retirement taken or other actions taken which
reduced, changed or
cut short employment due to Parkinson's disability? _______ Yes ________
No
If yes, what is or was the hourly compensation rate or equivalent for
the work previously
performed? $________________
How many hours per month are no longer worked that were worked before
disability
began? _____________________
If wages were reduced, by how much? $_________________________________
2. Disability insurance, Social Security/SSI or other compensation: If
younger than 65 and you
are being compensated for retiring early or cutting back employment due to
Parkinson's disability,
indicate amount of compensation: $___________ per _________ (month, year,
etc.)
Paid by whom (for example, disability insurance plan, SSI, previous
employer.):
___________________________________________________________________
3. Wages/productivity lost by caregiver of Parkinson's-afflicted person: If
younger than 65 and
work hours were cut, early retirement was taken or other actions were taken
reducing mployment
income due to necessity of caring for a Parkinson's disabled person? _______
Yes ________ No
If yes, note hourly compensation rate or equivalent for the work
previously performed:
$____________
How many hours per month are no longer worked that were worked before
disability
began?______________________________
If wages were reduced, by how much?
$__________________________________________
Notes (elaborate here on any of the above)
___________________________________________
______________________________________________________________________________
__
______________________________________________________________________________
__
______________________________________________________________________________
__
