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Thalidomide Insurance Survey
01.25.03

Please help us in our efforts to act as an advocate on your behalf by completing the following survey, which is intended for people for who have received thalidomide treatment or have had thalidomide recommended or prescribed by their physicians.

1.  Has your doctor ever recommended or prescribed thalidomide
     for the treatment of your myeloma?
        Yes         No

2.  Have you ever taken thalidomide to treat your myeloma?         Yes         No
             If yes, what was the maximum daily dose?
3.  If you haven't taken thalidomide, why not?        
4.  What is your primary health insurance?         Medicare  Other: 

If other, please explain:  (Please be as specific as possible)

5.  Do you have supplemental health insurance?         Yes         No

If yes, please explain:  (Please be as specific as possible)

6.  Does your insurance pay all or part of the cost of the thalidomide?         Yes         No

If not, what was the reason given for denying coverage? (Please be as specific as possible)

7. If you've taken thalidomide, did the disease respond to the treatment?         Yes         No
8.  Please provide the following so that we can contact you if follow-up is necessary:
 (all indvidual responses will be kept strictly confidential)
      

Name:    

Telephone:

eMail:

All indiviudal responses will be kept strictly conifidential

IMF Hot Line:
USA and Canada only: 800.452.CURE (2873)
Elsewhere: 818.487.7455

IMF International Headquarters:
12650 Riverside Drive, Suite 206
North Hollywood, CA 91607 USA
Tel: 818.487.7455
Fax: 818.487.7454
E-mail: TheIMF@myeloma.org


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