Personal Health Care Journal
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1 Personal Health Care Journal U.S. Administration on Aging Take an active role in your own health care!
2 Protect Detect Report Protect Your Personal Information Treat your Medicare, Medicaid and Social Security numbers like a credit card number. Remember, Medicare will not call you or visit you to sell you anything! Save Medicare Summary Notices (MSN) and Part D Explanations of Benefits (EOB), but shred them when they are no longer useful. Detect Errors, Fraud and Abuse Always review your Medicare Summary Notice and Part D Explanation of Benefits for mistakes. Compare them to prescription drug receipts and your record in this journal. Visit to access your Medicare account online. Make sure to look for: Charges for something you didn t get, billing for the same thing twice and services that were not ordered by your doctor. Report Mistakes or Questions If you suspect errors, fraud or abuse, report it immediately! Call your provider or plan first. If you are not satisfied with their response, call your local SMP.
3 Directions for using your personal journal... Take this journal to all your appointments. Ask yourself these questions before your health care appointment: Is this appointment going to be covered by Medicare or my other insurance? What are my symptoms? When did they start? What makes them better or worse? What over-the-counter or prescription medications am I taking? Write down the answer to these questions, as well as what happens during your visit, in this journal. Make sure that you understand what your physician is telling you before leaving your appointment. If you don t, ask them to try to explain what they are telling you in a different way. Take this journal with you when you travel, in case of emergency. Use this journal when checking your Medicare and health care paperwork for accuracy.
4 Important Contacts Your Local SMP Quality of Care Concerns? Contact your state QIO Social Security Administration Centers for Medicare & Medicaid Services (CMS) TTY MEDICARE TTY Fraud Tips Hotline HHS Office of Inspector General HHS-TIPS Federal Trade Commission ID Theft Hotline Eldercare Locator State Health Insurance Programs (SHIP) Long Term Care Ombudsman SMP Locator
5 Personal Information Name: Doctor s Name: Clinic Name: Phone Number: ( ) Clinic Address: City, State, and Zip: Pharmacist Name: Phone Number: ( ) Emergency Contact: Phone Number: ( ) If lost, please return to doctor s office.
6 Date Physician/Phone Number Reason for Visit List of Appointments
7 Date Physician/Phone Number Reason for Visit List of Appointments
8 Do you: Personal Habits Drink Alcohol: [ ] drinks per day Exercise: [ ] minutes per week Currently Smoke: [ ] packs a day Have smoked for [ ] years Date Allergic to what? Symptoms/Reactions Allergies
9 Family History & Health Problems/Conditions Condition Asthma: Cancer, Type : Diabetes, Type: 1 2 Heart Disease: High Blood Pressure: High Cholesterol: Stroke: Chronic Conditions: Depression: Dementia: When Patient was Diagnosed Parent or Sibling with Condition?
10 Medications Use this space to keep track of your medications and any changes that your provider makes. Drug Name Dosage Directions Purpose Date Started
11 Medications Use this space to keep track of your medications and any changes that your provider makes. Drug Name Dosage Directions Purpose Date Started
12 List of Medical Equipment and Supplies Date Equipment Provider of Equipment Advising Doctor
13 Date Type of Operation Hospital/Clinic List of Operations/Surgeries
14 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
15 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
16 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
17 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
18 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
19 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
20 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
21 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
22 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
23 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
24 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
25 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
26 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
27 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
28 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
29 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
30 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
31 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
32 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
33 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
34 Date Physician/Care Provider Question/Symptoms/Problems Answers/Explanations Services received (check-up, physical therapy, etc.)
35 Care Plan/Special Instructions from Doctor Personal Health Data Weight: Blood Pressure: Cholesterol: Blood Sugar:
36 Description of Tests and Screenings Test Name What is it? Does Medicare B Cover it? Bone Mass Measurements Helps determine if you are at risk for broken bones Yes, every 24 months if at risk Heart Screening Ask your doctor to test your cholesterol, lipid and triglyceride levels Yes, every 5 years Colorectal Cancer Screening Diabetes Screening Finds precancerous growths and can help find colon cancer early Tests are available if you have: high blood pressure, Dyslipidemia, obesity, or history of high blood sugar or two or more of the following characteristics: age 65+, overweight, family history of diabetes, delivery of baby weighing more than 9 pounds Yes, if age 50+ or at high risk Yes, based on results of test, you may be eligible for up to 2 per year
37 Description of Tests and Screenings Test Name What is it? Does Medicare B Cover it? Flu Shot Helps prevent Influenza, or the flu virus Yes, in Fall/Winter Glaucoma Test Helps detect the eye disease Glaucoma. Available if you are at risk. Yes, every 12 months Hepatitis B Shot Mammogram Pap Test & Pelvic Exam Helps protect you from getting Hepatitis B, a disease of the liver Checks for breast cancer before you or your doctor may feel it Checks women for vaginal and cervical cancers Yes, if at high or medium risk Yes, every 12 months for age 40+ Yes, every 24 months or every 12 if high risk
38 Description of Tests and Screenings Test Name What is it? Does Medicare B Cover it? Pneumococcal Shot Helps prevent pneumonia. Most people only need this once. Yes Prostate Cancer Screening One-time Welcome to Medicare Physical Stop Smoking Counseling Helps men find prostate cancer with a digital rectal exam and Prostate Specific Antigen (PSA) test Covers a one-time review of your health, as well as education and counseling about preventative services and referrals for other care. Part B deductible and co-insurance applies. Helps seniors quit smoking. Must have an illness from smoking or taking medicine affected by smoking. Counseling must be ordered by a doctor. Yes, every 12 months for age 50+ Yes, but only within the first 6 months of Part B coverage Yes, covers 8-12 visits
39 Notes
40 Notes
41 Your Local SMP Your local SMP Program offers the following: SCREENING health care bills or Medicare Summary Notices for possible errors, or overt fraud and abuse of Medicare and Medicaid programs. INFORMATION about how to protect yourself, report and respond to health care scams. ASSISTANCE with contacting your doctor or other health care providers to discuss billing problems if you are not comfortable doing it yourself. This project was supported in part, by grant 90AM3074, from the U.S. Administration on Aging, Department of Health and Human Services, Washington, D.C Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration on Aging policy.
42 Protect Detect Report Visit the SMP locator at: Report Suspected Medicare Fraud or Abuse to Your Local Agency on Aging
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