This document provides information and a worksheet to help Medicare beneficiaries choose a Medicare prescription drug plan. The worksheet guides the user in gathering personal information like medications, dosages, and preferred pharmacies. This information can then be used to compare and select a drug plan that meets the individual's needs and budget. Beneficiaries are advised to carefully consider their current coverage and consult resources like SHIIP for unbiased assistance in selecting a plan. The completed worksheet provides the details needed during enrollment.
Evaluación de las Estrategias de Enseñanza del Idioma Inglés en el Primer Cic...Jesus Mejia
Evaluacion de las Estrategias de Enseñanza del Idioma Inglés en el Primer Ciclo del Nivel Medio en el Politécnico Las Caobas y el Liceo Politécnico Las América en el Período 2004-2005. UNICARIBE
APLICACIÓN DE LA ESTRATEGIA “ANTES, DURANTE Y DESPUÉS” EN EL DESARROLLO DEL NIVEL DE COMPRENSIÓN LECTORA DE LOS NIÑOS Y NIÑAS DE 5 AÑOS DE LA INSTITUCIONES EDUCATIVAS INICIALES Nº 85, 89, 206 Y 215 DE AYAVIRI PROVINCIA DE MELGAR PUNO 2011
At a networking event or company meeting, you sometimes have to introduce yourself quickly. Presentation skills coach and professional speaker Gilda Bonanno explains how to introduce yourself with confidence and ease so you can make a connection to your audience, whether it's one or one hundred people.
For more on this topic, download Gilda's article, "How to Introduce Yourself Quickly" http://bit.ly/28ZXkvE
Get more public speaking and networking strategies from Gilda's e-newsletter: http://www.gildabonanno.com/Pages/newsletter.aspx
Teresa Clotilde Ojeda Sánchez: El Currículo Nacional de la Educación Básica es el documento marco de la política curricular que contiene los aprendizajes que se espera logren los estudiantes durante su formación básica, en concordancia con los fines y principios de la educación peruana, los objetivos de la educación básica y el Proyecto Educativo Nacional.
Este documento establece el Perfil de Egreso de la Educación Básica, las competencias nacionales y sus progresiones desde el inicio hasta el fin de la Educación Básica sus niveles esperados por ciclo, nivel y modalidades. Además, contiene orientaciones para la evaluación formativa y la diversificación curricular.
El Currículo Nacional es la base para la elaboración de los programas y herramientas curriculares de Educación Básica Regular, Educación Básica Alternativa y Educación Básica Especial, así como para la diversificación a nivel regional y de institución educativa. Asimismo, el currículo es el
elemento articulador de políticas e iniciativas de mejora de la inversión, la gestión y el fortalecimiento de capacidades en el sector, infraestructura y renovación de los espacios de
aprendizaje, recursos y materiales educativos, política docente y evaluación estandarizada.
Para su elaboración, el Ministerio de Educación ha promovido un proceso de consultas nacionales entre el 2012 y el 2016 con actores de sectores públicos y de la sociedad civil, docentes, especialistas, expertos nacionales e internacionales para la estructura y contenido curricular a lo que se suma la realización de consultas virtuales organizadas con el Consejo Nacional de Educación en el 2014 y 2015
Heritage Health Insurance: Eligibility, Renewal, & BenefitsTech Good Health
In this article, we will cover the basics of heritage health insurance and Nebraska's Medicaid expansion program. Renew the heritage health insurance easily.
Evaluación de las Estrategias de Enseñanza del Idioma Inglés en el Primer Cic...Jesus Mejia
Evaluacion de las Estrategias de Enseñanza del Idioma Inglés en el Primer Ciclo del Nivel Medio en el Politécnico Las Caobas y el Liceo Politécnico Las América en el Período 2004-2005. UNICARIBE
APLICACIÓN DE LA ESTRATEGIA “ANTES, DURANTE Y DESPUÉS” EN EL DESARROLLO DEL NIVEL DE COMPRENSIÓN LECTORA DE LOS NIÑOS Y NIÑAS DE 5 AÑOS DE LA INSTITUCIONES EDUCATIVAS INICIALES Nº 85, 89, 206 Y 215 DE AYAVIRI PROVINCIA DE MELGAR PUNO 2011
At a networking event or company meeting, you sometimes have to introduce yourself quickly. Presentation skills coach and professional speaker Gilda Bonanno explains how to introduce yourself with confidence and ease so you can make a connection to your audience, whether it's one or one hundred people.
For more on this topic, download Gilda's article, "How to Introduce Yourself Quickly" http://bit.ly/28ZXkvE
Get more public speaking and networking strategies from Gilda's e-newsletter: http://www.gildabonanno.com/Pages/newsletter.aspx
Teresa Clotilde Ojeda Sánchez: El Currículo Nacional de la Educación Básica es el documento marco de la política curricular que contiene los aprendizajes que se espera logren los estudiantes durante su formación básica, en concordancia con los fines y principios de la educación peruana, los objetivos de la educación básica y el Proyecto Educativo Nacional.
Este documento establece el Perfil de Egreso de la Educación Básica, las competencias nacionales y sus progresiones desde el inicio hasta el fin de la Educación Básica sus niveles esperados por ciclo, nivel y modalidades. Además, contiene orientaciones para la evaluación formativa y la diversificación curricular.
El Currículo Nacional es la base para la elaboración de los programas y herramientas curriculares de Educación Básica Regular, Educación Básica Alternativa y Educación Básica Especial, así como para la diversificación a nivel regional y de institución educativa. Asimismo, el currículo es el
elemento articulador de políticas e iniciativas de mejora de la inversión, la gestión y el fortalecimiento de capacidades en el sector, infraestructura y renovación de los espacios de
aprendizaje, recursos y materiales educativos, política docente y evaluación estandarizada.
Para su elaboración, el Ministerio de Educación ha promovido un proceso de consultas nacionales entre el 2012 y el 2016 con actores de sectores públicos y de la sociedad civil, docentes, especialistas, expertos nacionales e internacionales para la estructura y contenido curricular a lo que se suma la realización de consultas virtuales organizadas con el Consejo Nacional de Educación en el 2014 y 2015
Heritage Health Insurance: Eligibility, Renewal, & BenefitsTech Good Health
In this article, we will cover the basics of heritage health insurance and Nebraska's Medicaid expansion program. Renew the heritage health insurance easily.
I don't understand my marketplace insuranceSteve Levine
Half a year after policies purchased via the Affordable Care Act (ACA) online marketplace exchanges first took effect, research studies and media reports show that many of these newly insured Americans don’t understand their insurance or how to use it.
“Hey Doc” is pleased to reissue some of our articles and videos to help answer some critical questions.
Although the Affordable Care Act has benefited the health insurance consumer in many respects, it has also added to the confusion. This presentation, Given by Wanda Stephens in Raleigh, North Carolina, details some of the many facets to Obamacare in NC.
for more information visit http://www.hisonc.com/obamacare-north-carolina/
For many Americans, the ins-and-outs of finding individual health care coverage is complex and difficult to understand. Blue Cross Blue Shield of Michigan looks to ease the process, by providing our members with as much information and assistance as possible.
If you have questions regarding enrolling in a health plan, our health plan advisors are eager to help. Contact them at 888-899-4931, or go to bcbsm.com/myblue to learn more about plan options.
A Guide to Supplemental Security Income (SSI) for Groups and Organizations Julie Wilson
This booklet explains the SSI program to help institutions, groups, and organizations that have contact with people who get, or may be able to get, SSI.
Similar to Personal Info Worksheet Public.Pub (20)
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
1. Medicare Prescription Drug Coverage
Personal Information Worksheet
Beginning January 1, 2006, new Medicare prescription drug coverage will be available to everyone
with Medicare, regardless of income, health status, or how you pay for your prescriptions today. The
plans will provide insurance coverage for brand name and generic prescription drugs. The drug plans
may vary in what prescription drugs are covered, how much you have to pay, and which pharmacies
you can use. It is important that you choose a plan that meets your needs.
How should I use this worksheet?
Use this worksheet to help gather all the information you need to choose a Medicare drug plan that
meets your needs. Please fill out as much of the information in this worksheet as possible. You may
find it helpful to gather all your prescription drug containers and your red, white, and blue Medicare
card, as well as other health insurance cards you may have before you complete the worksheet.
Name: ________________________________________ Date of Birth: ______/______/________
Social Security Number: ______-_____-______ Telephone Number: (______) ______-________
Medicare Claim Number: ______-_____-________-_____
Part A Effective Date: _____/_____/________ Part B Effective Date: _____/_____/________
(if applicable)
Address: ________________________________________ County: ________________________
City: ___________________________________ State: __________ Zip Code: _____________
Do you have a residence in more than just the above-mentioned state? Yes No
• If yes, which state(s)? ________________________________________________________
Marital Status: Single Married*
* If you are married, your spouse will need to complete a separate worksheet.
Is your income less than $14,355 (single), or $19,245 (couple) and your assets/resources less than
$10,000 (single) or $20,000 (couple)?
Yes No I don’t know
• If so, did you apply for the extra help from the Social Security Administration in paying
for your Medicare prescription drug plan costs?
Yes No I don’t know
• If so, what was the response from the Social Security Administration?*
Accepted Declined Still pending
* If you received this letter, please keep it with this worksheet. You will need to refer to it for information when
you are choosing a prescription drug plan.
Nebraska Senior Health Insurance Information Program (SHIIP)
1-800-234-7119 1
2. What are my prescription drug coverage options?
You can get Medicare prescription drug coverage in one of two different ways:
1. Medicare drug plans. These plans add coverage to the Original Medicare Plan (and some
Medicare Cost Plans and Medicare Private Fee-for-Service plans). The Original Medicare Plan
is a fee-for-service plan. You can go to any doctor or hospital that accepts Medicare.
j
2. Medicare Advantage plans. These plans include Health Maintenance Organizations (HMOs),
Preferred Provider Organizations (PPOs), and Private Fee-for-Service (PFFS) plans. They offer
complete Medicare-covered health care, through a single plan, including drug coverage. Most
of these plans offer extra benefits and lower co-payments than the Original Medicare Plan.
However, you may have to see doctors, or go to hospitals, that belong to the plan.
What type of drug coverage do you currently have?
Prescription drug coverage through an employer or union health plan
Prescription drug coverage through a Medigap plan (Medicare Supplement Insurance)
TRICARE (military retiree benefits, VA benefits (Department of Veteran Affairs), or FEHBP
(Federal employee retirement benefits)
Prescription drug coverage through a Medicare Advantage (such as an HMO, POS, or PFFS)
Other: _____________________________________________________________________
None of the above
Please read this important information
If you are a member of a Medicare Advantage Plan, you may already have a prescription drug
benefit that will meet your needs. By joining a new prescription drug plan, your membership in your
Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well
as your prescription drug benefits. Contact your Medicare Advantage Plan if you have questions.
If you currently have health coverage from an employer or union, joining a new prescription drug
plan could change your current coverage. Read the communications your employer or union sends
you. If you have questions, visit their website, or contact the office listed in their communications.
If you currently have VA, TRICARE, or FEHBP coverage, you may not need to sign up for a
prescription drug plan. You should contact your benefits administrator before making any changes.
Are you a resident of a long-term care facility, such as a nursing home? Yes No
• If yes, what is the name of the facility? _________________________________________
• Address: __________________________________________________________________
• City: ________________________________ State: ______ Zip Code: ____________
• Telephone Number: (______) ______-________
Nebraska Senior Health Insurance Information Program (SHIIP)
1-800-234-7119 2
3. What is the maximum amount you are willing/ How would you like to pay your monthly
able to pay, as a monthly premium, for a premium? If you qualify for extra help with
Medicare prescription drug plan?* your prescription drug coverage costs,
Medicare may cover all or some portion of
under $20/month your plan premium. Please choose how you
$20 - $40/month want to pay any remaining premium.
$40 - $60/month Deduct it from my monthly Social
$60 - $80/month Security Administration benefit check.
$80 - $100/month Automatically deduct it from my bank
account each month.
* This is an estimate only and will be used to help
compare the different plan options.
I want to pay by mail each month.
List the prescription drugs you are currently taking (please print; use additional pages, if needed).
This information can be found on your prescription containers. If you need assistance, ask your
pharmacist. The correct spelling of the drug name, the dosage and the frequency you take each drug,
and the price you are now paying is relevant information in comparing plans.
Drug Name Dosage Taken how often Price per month
Nebraska Senior Health Insurance Information Program (SHIIP)
1-800-234-7119 3
4. List the name, city, and zip code of the pharmacies you prefer to use (list up to three).
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
Please read and sign below
By joining a Medicare prescription drug plan, I acknowledge that the plan/organization I choose will
release my information to Medicare and other plans as is necessary for treatment, payment, and health
care operations. The information on this personal information worksheet is correct to the best of my
knowledge. I understand that if I intentionally provide false information on the worksheet, I may be
disenrolled from a plan.
Signature: ______________________________________________ Date: ____________________
By affixing my signature below, I am acknowledging that I am making my enrollment decision freely
and voluntarily. While I may have received information from a volunteer counselor, the final decision
was made of my own free will and choice. I further understand that the counselor who assisted me is a
volunteer and has merely provided me with information to assist me in my decision. I hereby release
any and all liability that may possibly be attributable to the volunteer counselor and agree not to pursue
any legal action against the counselor for actions taken in their capacity as a volunteer counselor.
Signature: ______________________________________________ Date: ____________________
What should I do with my completed worksheet?
Once you complete this worksheet, you can use it to find a Medicare drug plan that meets your needs.
You may compare and enroll on your own through the www.medicare.gov website, with the drug plan
sponsor directly, or you may receive assistance from:
• Medicare. Speak with a customer service representative by calling 1-800-MEDICARE
(1-800-633-4227).
• The Nebraska Senior Health Insurance Information Program. You can meet with a
volunteer counselor, or receive free, unbiased information by calling 1-800-234-7119.
Nebraska Senior Health Insurance This publication is for informational purposes
Information Program (SHIIP) only and is available to the public. Neither the
SHIIP program nor the Nebraska Department of
1-800-234-7119 Insurance endorses any specific company,
product or plan of insurance.
OUT05142
Created October 2005 4