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International Myeloma Foundation - Thalidomide Insurance Survey
01.26.03
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

If you answered "No" to question #1, please skip to question #8.
 2.  Have you ever taken thalidomide to treat your myeloma?
 Yes         No

If yes, what was the maximum daily dose?
<50mg (less than 1 pill)  50mg (1 pill) 
100mg (2 pills) 150mg (3 pills) 
200mg (4 pills)  more than 200mg

3.  If you haven't taken thalidomide, what are the reasons?
 

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)

 

If you are paying for all or part of the cost of your thalidomide, how much are you personally paying each month?

7. If you have taken thalidomide, did the disease respond to the thalidomide treatment?
Yes    No
8.  Please provide the following so that we can contact you if follow-up is necessary:  
Name:
Tel::
eMail:

(All indvidual responses will be kept strictly confidential.  Contact information will not be provided to any third parties.)

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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