Parkinson Action Network Cost Evaluation form-
If you haven't completed and returned a Cost Evaluation form you can use the
convenient form below.
Moreover, organizing your support group to do the same would greatly assist
our efforts. If you are a physician or support group leader, please call our
office to receive forms and distribute them to your members. This
information will help us all in the effort to demonstrate that Parkinson's
deserves more research funding.
Please copy and paste this message into a new "Compose Mail" window and fill
in as much info as possible. Then email to [log in to unmask]
State______________Zip______________ .
Age: ______ Age at 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 $______________________per year*.
(for example, Blue Cross, Kaiser, or Medicare): [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(a). 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.
2(b). Cost of medical care for Parkinson's-caused problems Doctor visits,
other medical procedures, treatments or other care needed as a result
of Parkinson's-caused problems (for example, injuries from a
fall)paid by you and not reimbursed: $______________________per year .
Neurologists visits, other procedures, treatments or other care needed as a
result of Parkinson's-caused problems, paid for 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 $______________________per year*.
(Blue Cross, Kaiser or Medicare):
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, air fare, 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
disabled by Parkinson'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):________________________________________________
_____________________________________________________________________________
