Attachment A: Sample Diagnosis and/or Treatment ... - …
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Cancer Treatment Plan and Budget
Name of Organization/Entity applying for Grant: ___________Your County Health Department________________________
Patient Name: ______Jane Doe____________________________ Date of Birth: __________01/01/1943____________
Diagnosis: _Invasive well-moderately differentiated adenocarcinoma of the sigmoid colon_ Date of Diagnosis: 08/07/2008
Comments:_____________________________________________________________________________________________
_______________________________________________________________________________________________________
Treatment Plan from _09/2008__ to _12/2008__ Primary Treating Physician’s Name: ________Dr. Dolittle_____________
(date) (date)
|Procedure and Frequency of Treatment |Date Anticipated |Estimated Costs |Basis for costs |
| | | |(Medicaid rate, HSCRC-regulated rate, or MHIP rate) |
|CT Chest |9/2008 |259 |HSCRC |
|CT Abdomen |9/2008 |259 |HSCRC |
|Outpatient Laboratory, EKG, blood work, etc. |9/2008 |500 |Medical Assistance |
|Surgeon | | |Medical Assistance |
|Anesthesiologist | | |HSCRC |
|In-patient pharmacy | |500 | |
|In-patient Laboratory, EKG, blood tests, etc. | |1000 |HSCRC |
|Inpatient Pathology | |236 |HSCRC |
|Hospital room fee, 7 day | |7 x 1500=10500 |HSCRC |
|Operating Room Fees | |2264 |HSCRC |
|Initial Surgeon visit-in patient | |24 |Medical Assistance |
|Surgeon visit X 7 – in patient | |112 |Medical Assistance |
|Surgical Outpatient visit X 4 | |155 |Medical Assistance |
|Oncologist out patient visits X 16 | |691 |Medical Assistance |
|Out-patient pharmacy | |3000 |Medical Assistance |
|Out-patient laboratory | |500 |Medical Assistance |
|Sub Total for Treatment | |$20000 | |
|Indirect costs | |$1400 | |
|(Maximum of 7%) | | | |
|Total Requested | |$21,400 | |
|(Treatment + Indirect) | | | |
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