Key Health Care Forms and Documents that Keep Patients in Control

Last revised: 10/02/2023 (under review)
By W. Kolber, MHA

The linked documents in this post are examples of the health care forms and legal documents that are used to help people keep control of their health care choices. Since states have different laws please make sure to check with your State Health Department and/or an attorney familiar with the laws in your state to ensure you understand what is required in your state.

  1. Living Will: Also known as an “advance directive,” a living will outlines the patient’s preferences for medical treatment in case they are unable to communicate their wishes. It often addresses end-of-life decisions, such as the use of life-sustaining treatments. You can find, download, and print free advance directive forms for your state. You may need to have your form witnessed or notarized, so be sure to read the directions closely. Here are some ways you might find free advance directive forms in your state in English and Spanish.
  2. Medical Durable Power of Attorney (MDPA): This document designates a person (an “agent” or “proxy”) to make medical decisions on behalf of the patient if they become unable to make those decisions themselves. The agent’s authority is specified in the document by the patient. It may be as limited or broad as the patient prefers.
  3. Advance Healthcare Directives: This document combines a living will and a healthcare power of attorney. It lets patients outline their medical preferences and designate a healthcare agent. So what happens if the agent who was appointed in the POA tries to go against the wishes of the principal written within the living will? Most states will proclaim that the preferences of the patient override the authority of the attorney-in-fact.
  4. Do Not Resuscitate (DNR) Order: A DNR order instructs medical professionals not to perform cardiopulmonary resuscitation (CPR) in case of cardiac arrest. This decision is often made in consultation with the patient, their family, and their healthcare provider. A DNR must be obtained from and signed by a doctor – this is not a form you can download on the Internet and sign on your own. Because it is a doctor’s order, only a physician can revoke a DNR.
  5. HIPAA Authorization: The Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers to protect the privacy of a patient’s medical information. A HIPAA authorization form allows the patient to grant specific individuals or entities access to their medical records and information.
  6. Medical Release Form: Similar to a HIPAA authorization, a medical release form allows the patient to grant permission to healthcare providers to share their medical information with specific individuals or organizations, such as family members or other medical facilities.
  7. Financial Power of Attorney: While not exclusive to healthcare, a financial power of attorney designates someone to manage the patient’s financial affairs if they become incapacitated. This can be relevant for handling medical bills and insurance claims.
  8. Organ Donation Consent Form: Patients can express their intention to donate organs or tissues upon their death or when they are still alive by signing an organ donation consent form. This decision can be crucial for saving lives through organ transplantation.
  9. Patient Registration Form: This form collects basic information about the patient, including contact details, personal information, medical history, insurance information, financial information, consent and authorization, emergency contacts, signatures and dates. It is typically filled out when a patient establishes care with a new healthcare provider. The specific content and format of patient registration forms varies by healthcare facility and may also be influenced by legal and regulatory requirements.
  10. Release of Liability: In certain cases, patients might need to sign a release of liability form before participating in activities that carry inherent risks, such as clinical trials or experimental treatments.
  11. Letter to Request Copies of Medical Records:
  12. Letter to Appeal a Denial of Coverage: Example of a letter that can be used to appeal a denial of health insurance coverage for a diagnostic test or a medical procedure.


  1. NIH, National Institute on Aging, NIA
  2. American Association of Retired People, AARP
  3. American Academy of Family Physicians
  4. Colorado Gerontological Society
  5. The Center for Healthcare Rights
  6. USA.Gov
  7. U.S. Department of Health and Human Services, National Institutes of Health


You just got the news that you’re very sick. To ensure your quickest, safest, and best outcome you must be actively engaged and lead you own care. As soon as you can balance your emotions, you will have to make important decisions about your doctors, treatment, care, and finances.

Click here for an even more detailed step-by-step explanation of each step.


During the next few days, weeks, and months you must learn enough about your choices to make informed decisions. Likely, your doctor or health insurance provider has provided or will provide information specific to your diagnosis. This might be a pamphlet, web page, video, support group, app., or something else.


It will take time before you have processed your new diagnosis and balanced your emotions. It may take just a few days or several months. There are a wide range of emotions that people feel after getting a serious diagnosis. It’s important to realize that these feelings are all natural. It’s common to feel grief shock, anger, frustration, worry, and other emotions. It’s also common for people of any age to experience short-term changes in behavior after hearing such serious news.  Be reassured that in most cases your emotions and any physical changes like loss of sleep or diet are temporary. They typically start returning normal within weeks when there is support.  

KEY TIP: Science shows that you increase your chances for positive outcomes when you find at least one person, or a support group, you trust to talk to.

When you walk this journey alone, you increase the risk of things not working out for the best for many reasons. If there is no one in your life that you trust enough, consider finding comfort and support by seeking out and communicating with others who have experienced a similar diagnosis, and often recovery.

Shyness doesn’t matter in these groups. You can stay anonymous and just listen and learn from other posts and replies. Sometimes the comfort of being anonymous also lets you express your feelings to others who you hardly know, because you have shared a common experience.

You may also connect with care givers and family members as well as patients, both current and past. Support groups are often available in-person in most urban areas and online for anyone with a smart phone and/or Internet access. Here’s a link to hundreds of local and online support communities organized alphabetically by diagnosis.

KEY TIP: Trust, but research and verify everything you learn in chat rooms with your physicians and through published, peer-reviewed research and patient use cases.

If you’re emotions have not begun to balance within 30 to 60 days engage the support of your doctor. You’ll make better decisions once your emotions settle. It also is not advisable to make any immediate decisions regarding your health unless your doctor tells you that you must act quickly. If you must make a quick decision, seriously consider a second opinion from another clinician or experienced provider in as short a time as possible. You can stay within your network for the lowest cost or seek out world renowned clinicians at providers like the Cleveland Clinic, Stanford Health Care, and other major health centers for virtual second opinions within days.

KEY TIP: It’s a best practice to always contact your health insurance provider and ask questions until you understand any cost to you, and what you can do to get the lowest cost, highest quality care.

If your reactions to your diagnosis do not get better within a few weeks or if they get worse, ask your doctor about mental health counselors and support that is available. Click here for an even more detailed step-by-step explanation of each step.

Last revision: 08132022

A Patient’s Place – Initial Assessment

apatientsplace-logo-v3 Intake Form


Intake rep.:
Caller Name:
Emergency (circle one): Yes or No
Is Caller Patient?:
Caller Phone:
Caller Email:
Patient Name:
Patient Birth Date:
Situation – General:
Description of Problem:


Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Steps Taken to Resolve Issue:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Parties Involved and Their Roles:
Goal or Desired Outcome (Primary):
Goals or Desired Outcomes (Secondary):
Goals or Desired Outcomes (Secondary):
Health Insurance:
Stress Level (1 to 10):
Access to Primary Care:
Situation – Detail:
How Problem Impacts Patient:
Confirmation with Caller of Key Issue:
Medical Diagnosis:
History of Key Issue :
Related Problems:
Access to Support:
Description if “N”:
Access to Transportation:
Description if “N”:
Access to Safe Housing:
Description if “N”:
Access to income:
Description if “N”:
Access to Nutrition:
Description if “N”:
Current Employment:
Description if “N”:
Access to Medical Records:
Description if “N”:
Client Question List:
Client Contact Preferences:
Client Backup Contact Method:
Release of Medical Information Under HIPAA Needed:

Create Client Record in CRM



Assign & notify team lead in CRM

Research how others have solved the key issue.
Identify / document needs & resources
Review data and guidelines on key issue resolution
Identify possible solutions and the people involved
Draft Next Step Resolution Plan (NSRP)
Document NSRP in Client CRM



Re-engage Caller:
Identify Changes to Primary Problem and Situation:
Review NSRP “Key Recommendations”:
Affirm Primary Goal:
Communicate Possible Solutions:
Identify Client Questions:
Answer Questions:
Chosen solution:
Document each party’s roles:
Review / Document “Next Steps” Plan (with dates):
Agree on closing the loop on actions:



Action Items- Solution Implementation:
Complete Agent and Liability Forms:
Begin implementing solutions:
Create Care Team in CRM:
Identify plan to monitor progress:
Begin Plan Implementation:

Document Each Action Taken in Care Coordination Platform
Close Case at Goal (Row #25) Attainment



Trustworthy Sources of Federal/State/Local Information


Caronavirus – COVID-19

Last update: 3/13/2020

It’s natural for everyone to want information about COVID-19 in the U.S.

If you want information, there’s a curated list of trustworthy phone numbers and websites below specifically for COVID-19 (Coronavirus) information and help.

All the phone numbers and website links below are specific to COVID-19 (Cornoavirus). They are from curated and trustworthy federal, state, and local governments and agencies, and educational institutions. The list will be updated regularly as new, credible information becomes available.

Please do not to click on unsolicited emails offering information about COVID-19, treatments, cures, or anything else. No matter how legitimate the email looks.

There is far too much misleading and incorrect information being put out to the public on the Internet and via the media Scammers are already using the CDC and state health department logos to place malicious software on computers as soon as emails are opened.

Every person should take personal responsibility to assess the accuracy of the  information you are consuming.

Phone Numbers


1-888-463-6332: Food & Drug Administration Information Line
1-800-232-4636: Centers for Disease Control and Prevention


617-534-5050: Boston Public Health Commission
760-837-8988: California., Eisenhower Health
866-779-6121: Florida Department of Health
513-529-9000: Miami University, OH
855-600-3452: New Mexico Department of Health
410-455-1000: University of Maryland
304-598-6000: West Virginia University
801-584-2575: Veterans Administration Rocky Mountain Network
877-741-3400: Veterans Administration Tampa, FL




Centers for Disease Control and Prevention:
EPA’s List of Disinfectants for COVID-19:


State Health Department Websites:
California, Los Angeles:
California, Oakland:
California, Santa Clara:
Florida, Tampa:
Hawaii, Maui County:
Illinois, Kane County:
New Mexico:
New York:
New York, Rochester:
New York, Rockland County:
North Carolina:
Pennsylvania, Alleheny County:
Rhode Island:
Texas, Dallas:
Washington (state):
Washington, Island County:
Washington, Maple Valley:
Washington, Seattle & King Counties:

Get Email Updates

Disclaimer: is not responsible for any content or advice presented or given on the websites or phone centers included in this article.


Need Free Help Fast?

For no fee (0$)) you can contact the Patient Advocate Foundation (PAF) to help you solve your insurance issues. The PAF employs case managers to help people with financial, insurance, and employment related issues relating to chronic, debilitating, and life-threatening illnesses. You can contact the Patient Advocate Foundation by calling 1-800-532-5274, by email at, and from their website at

For issues related to Medicare or Medicaid, you can call the Medicare Rights Center phone hotline from 9:00am to 5:00pm Eastern time at 1-800-333-4114, or the official Medicare information line 24 hour a day, 7 days a week at 1-800-633-4227.


Health Insurance Basics

Today, health insurance helps pay for some of the medical costs associated with prevention, certain screenings, basic illnesses, and many major conditions. However, it is highly likely that you will still have out-of-pocket costs. When you add your out-of-pocket expenses to your monthly premium, which is the amount you pay every month for your policy, you can figure out about how much you will have to spend on your health care.

Before you start comparing policies it helps to know a few key terms:

Premium: The monthly amount you pay for your policy.

Deductible: How much money you have to pay each year before the policy coverage starts.

Co-pay: The amount you have to pay for services.

Co-insurance: The percentage of the total charges that you have to pay in addition to your co-pay.

Out-of-Pocket Maximum: The top amount a member will spend in cash outside the premium during the benefit year.

Since consumers are paying more of their medical expenses through higher premiums, higher deductibles, and co-insurance it is important to know exactly what your health insurance plan covers and what it does not cover. For most insurance plans the important rules fall into the following groups:

Doctors and Hospitals

Insurance providers sign contracts with certain doctors, hospitals, and providers to care for their plan members. Your plan will likely refer to these groups as providers. In return the doctors, hospitals, and providers agree to certain reimbursement rates for the services they provide, and to follow the plan’s rules. This group of providers is often called the plan’s network.

Tip: Your insurance company might not pay for you to go to a provider who is not in its network, or it may pay much less. You are responsible for the part of the bill that the plan doesn’t pay.

Even if your doctor is part of the plan’s network, he or she may prefer to send patients to a hospital that is not in the network. If that happens, ask if your doctor can send you to a hospital in the network. If that is not possible, you can ask the insurance company if it will approve the use of the out-of-network hospital. If no other arrangements can be made you might have to choose a different doctor who has privileges at a hospital that is in your network. Your insurance company customer service can help you find qualified doctors who practice at in-network hospitals and treatment facilities.

Rules for Seeing Specialists

Many managed care plans, especially health maintenance organizations (HMOs) will not pay for you to see a specialist unless your primary care physician thinks it is necessary. If you see a specialist without a referral you might have to pay more for the care you receive.


Rules for Getting Expensive Services

If your doctor decides that you need to go to the hospital, have surgery, or have certain tests, your insurance company may refuse to pay for it unless it can pre-authorize the treatment; (approve it beforehand).



Almost every managed care plan has a drug formulary. A formulary is a list of prescription medicines that your health plan has approved. If a drug isn’t on the formulary you will probably have to pay more for it. Your insurance company can give you a list of drugs that are on the formulary. If necessary, show the list to your doctor when the doctor writes you a prescription.


Choosing a Health Insurance Plan

Here’s how to choose the health insurance that works best for you.

Step 1. Understand the details of each policy.

If you don’t understand the details call the insurance provider and ask them to explain how much money you will be responsible for paying on each plan you are considering. Make sure to ask about your monthly payment, your deductible, your coinsurance, and to get a list of benefits; (what is covered, and what is not).

Step 2. Calculate your expected annual cost for each policy.

Calculate your health costs for the coming year to see if you are better off with a high deductible and lower monthly bill, or a lower deductible but higher monthly premium. The way to do this is to add the amount of money you spent out of pocket on prescriptions, doctors’ appointments, and medical devices and equipment in the past year and compare that with the co-payments and/or co-insurance offered by the plan you are considering.

If you choose a high-deductible option, consider using a Health Savings Account (HAS) to set aside pretax dollars to pay for medical expenses. HSAs are explained later in this section. You must record your use of this account and keep detailed records. Don’t forget to add the expenses for all of the people who will be covered by the policy. As best you can, consider any additional or likely expenses for the upcoming year.

Step 3. Based on the type of services you expect to need, compare the costs of using doctors who are in the network vs. doctors and hospitals that are not in the network. Check the maximum out-of-pocket amount to see whether the deductible, co-payments and pharmacy expenses can be applied toward it.

Step 4. Before you decide what policy is best for you, take the time to contact the insurance company and get answers to all of your questions.

Step 5. Compare the performance of the plans you are considering.

Many health care organizations, such as the nonprofit National Committee for Quality Assurance (NCQA), gather data on how well doctors and facilities in managed-health-care plans follow practice guidelines. Then they use the results to grade those practices and facilities. To see how your health plan and others in your area fare, go to Experts hope that eventually the grades will extend all the way down to practice groups and even individual physicians.


Working with Your Insurance Company

Health insurance plans can be confusing.  However, you are responsible for knowing what benefits you are entitled to under your policy.  If you do not fully understand something, ask your insurance representative or your employer’s benefits administrator to explain it.

Following the steps below can help you work with your insurance company to make sure you receive all the benefits to which you’re entitled.

Step 1. Make sure you have accurate contact information for your insurance company.

Step 2. Contact your insurance provider and request an up-to-date copy of your plan, and its summary.

This will tell you how your plan works, its benefits, and how to file a claim. Be confident when calling your insurance company. You are their customer. You have the right to receive complete information regarding your health benefits.  Your insurance company’s customer service representatives are there to assist you.  Part of their job includes answering questions to your satisfaction.  Communicate as clearly and calmly as possible. Be courteous and polite, even if you are not happy with your insurance provider. The person on the other end of the phone probably wasn’t responsible for what ever has disappointed you. Remember that your goal is to get coverage for what you need.

If you are met with resistance, simply restate your request. Carefully follow the steps outlined by your health plan for requesting prior authorization, submitting claims or filing appeals.  Not following these steps may result in a delay in processing or a denial of your request for coverage.

Tip: Don’t give up.  Don’t take “No” for an answer. 

If you have tried discussing your request with your health plan’s customer service representative, but are not satisfied with how your insurance matter was handled, ask to speak to a Supervisor in the Customer Service Department, or the Manager or Director of Customer Service, or Member Services.

Follow up in writing or email after speaking with a health plan representative on the phone.  Keep your correspondence simple and to the point.  Include relevant dates, names of representatives with whom you spoke to, and what they told you.  Also be sure to include your name, policy number and any other identifying information.  Do not hesitate to ask for help from your employer’s human resources department and your healthcare provider.

In many cases, your employer makes decisions about what will and will not be covered under your health plan.  Your employer’s support may result in the approval of your request for coverage.  Having your healthcare provider (doctor) contact your insurance representative can also be helpful since he/she can support the communication that you have had with your insurance company as to why the requested medical products or services are needed.

Advocate for yourself at all times. If needed, write to your state health insurance commissioner and/or your state and federally-elected representatives to enlist their help. Informing them of your health needs and what has occurred with your health plan insurance claims.  Notify your insurance company that you have requested help from the State Health Insurance Commission and other agency representatives in resolving difficulties in meeting your healthcare needs.

You can make a difference! Remember the expression, “the squeaky wheel gets the grease.”  The more you make your needs known, the more likely you will get those needs met!


Working with Insurance Providers after a Diagnosis

Once you have determined your preferred treatment with your doctor(s) find out which procedures require you to pay a co-payment and co-insurance, and how much they will be. If you buy your own insurance rather than receiving it as a benefit of your or your spouse’s employment, make sure you pay your premiums on time.

Tip: Request a Case Manager to speak with each time you call your insurance company.

Tip: Make notes about each call. Record of the date, the name of anyone you spoke with, and any instructions you were given. You can save and organize your records with a few file folders, a more elaborate system, or by scanning and saving them on your computer.

If your doctor wants to refer you to one or more specialists make sure they are covered in your plan. If they are not in your network and you still feel you want to see them, consider that you will likely be responsible for that doctor’s entire fee.

Organize your records and paperwork, including bills, claims, payments, a record of phone calls to and from doctors and your insurance company, and letters to and from your employers, doctors, and insurance company. Include dates, who you spoke to, and a brief note for each occurrence.

If you’re required to submit bills to your insurance company, try to send them in as soon as you get them. If you’re recovering from treatment, ask a loved one or friend to help you.


Handling Claims

Keep detailed records of all the claims you submit and note when they were submitted, whether they’re still pending, and when they were paid. Also keep copies of any and all paperwork related to your treatment, diagnosis, and insurance claims, including:

  • Requests for sick leave
  • Receipts
  • Letters from your doctor, employer, and insurance company
  • Letters you write to your doctor, employer, and insurance company
  • Bills
  • Summaries of phone calls to your insurance company, including the date, time, and the person’s name to whom you spoke


Managing Costs 

Know if the procedure you want requires you to pay a co-payment and co-insurance and how much they will be. Ask how you are required to pay for treatment. Does your insurance company make the first payment? Or do you pay the bill and then get reimbursed? If you’re required to submit bills to your insurance company, try to send them in as soon as you get them. If you’re recovering from treatment, ask a loved one or friend to help you. Section 13 of this book is devoted to helping you reduce and manage your healthcare costs.


Fighting Insurance Denials

Many insurance companies deny claims just because they know there is a good chance the consumer will not appeal. Just by taking control and advocating for yourself you let the insurance company know that you are not going to go away without a fight for the coverage you expected and are paying for. Sometimes just being the persistent and polite pest is enough to get your denial reversed.

So, how do you know if your claim is denied? An Explanation of Benefits (EOB) which is sent by your insurance company to you is one of the only ways to determine what the insurance paid to the provider and how much you may still owe. The EOB should also disclose if your claim has been denied. If the insurance company portion of the payment shows $0, this can indicate a denial. The payment amount should be followed by a “Reason Code(s).” This code provides an explanation for the lack of payment. The insurance company may also send you a letter confirming the denied medical claim and detailing their reason(s) for denial.

Make sure to keep copies of all correspondence you receive from the insurance company, including denial letters and approval letters.

Make copies of all correspondence you send to the insurance company, including letters, your health history, medical files, doctor’s letters, etc. As mentioned earlier in this section, keep a written record of all contact and phone calls with the insurance company

If your insurance company denies a claim, follow the steps below:

Step 1. Check your plan to make sure the benefit you want is included. Make a note of the part of the policy that leads you to believe your claim should not have been denied.

Step 2. Collect and organize all information pertaining to the denied claim. Make sure you have the original bill (containing the date(s) of service and the provider’s name), your EOB, and your insurance card before placing a call. If the insurance company sent you a letter have that available as well.

Step 3. Call the number provided on the letter from your insurance company, or if you did not receive a letter call the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided the claim will be re-processed and you’re done.

Step 4. Sometimes claims are denied because of miscoding. If that is the case, ask your doctor to review the coding and re-submit a request with more specific medical justification for the procedure or medication, and you should be done.

Step 5. If your claim was not denied for missing information or miscoding, find out why it was denied and how you can file an appeal.

Step 6. Ask the insurance provider’s representative for suggestions or guidelines for appealing a denial.

Step 7. If you would like an appeal form, ask them to send one via the mail or email.

Step 8. Make sure you have the address for the appropriate department to return the completed appeal documents.

Step 9. Always keep a record of the date, time and the name of the insurance provider representative you talked with, along with a brief summary of the discussion. Keep this with copies of any documents you send to the insurance company.

Tip: For no charge, the Patient Advocate Foundation (PAF) will help you solve your insurance issues. Contact the Patient Advocate Foundation by calling 1-800-532-5274, by email at, and from their website at

Step 10. In appealing the denied claim, you should have the opportunity to review the information the insurance company used to make their decision.

Step 11. If necessary, get your doctor involved. Their office should have staff that can help explain why the procedure or care is needed, or medically necessary.

Step 12. Get help wording your appeals so that it mentions medical problems and does not include words that automatically trigger denials. Talk to the person who handles insurance claims at your doctor’s office. This person may be able to help you with the appeal process and provide any documentation your insurance company requires.

Step 13. Remember each insurance company has its own appeal process. Before submitting your information, make sure you have completed and include all the required paperwork. Once all your documents are complete make a copy of everything for your reference.

Step 14. Continue to go through all levels of appeal.

Step 15. If your insurance company denies the claim again, in most cases, you can contact them to request an external appeal. Usually this appeal will be conducted by a medical professional or group of medical professionals not associated with the insurance company.

Step 16. Sometimes it takes the threat of a lawsuit to get your insurance company to move.

Send all your correspondence to the insurance company via certified mail with return receipt. Be persistent.  Remember that a denial is not necessarily the final word.  Ask your insurance company to reconsider their decision and follow-up to make sure they take action.



Medicare is health insurance offered by the federal government to people who are 65 or older and meet specific eligibility requirements. The specific requirements can be found on the Medicare website at Some people qualify for both Medicare and Medicaid. This is called “dual eligibility.”

The Original Medicare Plan is a fee-for-service plan that covers many healthcare services and certain drugs. Usually, you can go to any doctor or hospital that accepts Medicare. With all the recent and expected changes to Medicare, it is important for you to contact your local Medicare office to discuss your situation every time you expect to need services. At the end of your conversation you want to know as best you can what expenses Medicare will cover, and what your financial obligations will be.

Medicare has four parts:

Part A helps pay for hospital bills. Part B is a supplemental insurance option that pays for physician services and supplies outside of the hospital. Part C includes private health plans that are Medicare approved. Part D is prescription drug coverage.


Part A: Hospital Coverage – The Basics

When you sign up for Medicare, you automatically get Part A. If you or your spouse paid Medicare taxes while you worked, you will not have to pay a monthly premium for Part A coverage. If you paid Medicare taxes for less than 7.5 years your premium was about $460 per month at the time of researching this book. If you paid Medicare taxes for more than 7.5 years but less than 10 years, your premium was about $255 per month.

Part A covers much of the cost of inpatient hospital stays including semi-private room, food, tests, and doctor’s fees. However, Medicare beneficiaries still pay a portion of their costs. Part A also covers brief stays in a skilled nursing facility if certain criteria are met. In general, the criteria are:

  • A preceding hospital stay must be at least three days, three midnights, not counting the discharge date.
  • A nursing home stay must be for something diagnosed during the hospital stay, or for the main cause of hospital stay.
  • If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision, then the nursing home stay would be covered.
  • The care being rendered by the nursing home must be skilled.

The maximum length of stay that Medicare Part A covers in a skilled nursing facility per ailment is 100 days as of the writing of this Guide. The first 20 days are paid for in full by Medicare, with the remaining 80 days requiring a co-payment. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset, and the person qualifies for a new 100-day benefit period.

Medicare part A does not pay for custodial, non-skilled, or long-term care. It does not pay for help with activities of daily living (ADLs). Examples of ADLs are personal hygiene, cooking, cleaning, bathing, etc.

Part B: Medical Coverage – The Basics

The purpose of Part B is to cover physician and medical services not covered under Part A. The additional services covered typically include:

  • Doctor visits as an inpatient or outpatient, at a hospital, doctor’s office, or health care facility.
  • Laboratory tests and X-rays.
  • Physical therapy or rehabilitation services.
  • Ambulance service.
  • Some home health care.
  • Some medically necessary medical equipment.

Medicare Part B is optional. It can be deferred if the beneficiary or their spouse is still actively working. However, you must sign up for Medicare Part B if you want it.

If you sign up you will pay a monthly premium and yearly deductible. The premium cost may increase each January, and it is deducted from your Social Security check. You are also responsible for a twenty percent co-payment for the services and supplies you are approved for. If you do not sign up for Medicare Part B when you are first eligible, you may have to permanently pay a higher monthly premium.

Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments, and other outpatient medical treatments administered in a doctor’s office.

Tip: The actual administration of medication is covered under Part B only if it is administered by the physician during an office visit.

Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following a mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also most often covered.


Deductible and Coinsurance

After a beneficiary meets the yearly deductible, they are required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B. Lab services are an exception, and they are often covered at 100%. You may also be required to pay an excess charge of 15% for services rendered by non-participating Medicare providers.

Part C – Private Health Plans (Medicare Advantage)

Medicare part C gives consumers the option to receive their Medicare (Parts A and B) benefits through private Medicare approved health plans. When you join this type of plan you are still in Medicare. Often called Medicare Advantage Plans, private plans often cover more services and have lower out-of-pocket costs than the original Medicare plan.

These plans are not available in all areas. They usually include: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Medicare Special Needs Plans, and Medical Savings Account plans (MSA)

Medicare Advantage plans provide hospital and medical coverage and medically necessary services. They generally offer extra benefits, including drug coverage. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a set amount every month for each member.

Members of these plans pay a monthly premium to cover items not covered by traditional Medicare; (Parts A & B). These items may include prescription drugs, dental care, vision care, and gym or health club membership. These plans often restrict members to a network of providers they can use without having to get special permission and/or paying extra themselves. That means you may have to see the plan’s doctors, and go to certain hospitals to get care if you want the plan to pay their part of the expense

If you have a Medicare Advantage plan, you don’t need supplemental insurance, or a Medigap policy.

Medigap Plans – The Basics

Medigap policies are standardized by the Centers for Medicare & Medicaid Services. They are sold and administered by private insurance companies. They cover some of the out-of-pocket costs from Medicare part A & B. Medicare beneficiaries can not have both a Medicare Advantage Plan and a Medigap Policy. Medigap policies may only be purchased by beneficiaries that are receiving benefits from Original Medicare; (Parts A & B).

Medigap plans are not like Medicare Advantage plans that run HMOs and PPOs. Examples of expenses that are usually covered by Medigap plans include co-payments, coinsurance, and the yearly Medicare deductible.

Tip: A Medigap policy can only cover one person. If you are married both you and your spouse must buy separate policies.

There can be big differences in the costs and benefits of various plans. Therefore, the government requires that the companies providing these plans must clearly identify that the policy is a “Medicare Supplement Insurance” on the front of each policy.

Remember, that Medicare pays for many healthcare services and supplies, but it doesn’t pay all your health care costs. There are costs that you must pay, like coinsurance, co-payments, and deductibles.

You might want to consider buying a Medigap policy to cover these gaps in Medicare coverage, or a Medicare Advantage policy to replace your original Medicare Plan. Some Medicare Advantage Plans include prescription drug coverage. You can also add prescription drug coverage by joining a Medicare Prescription Drug Plan.


Comparing Plans and Plan Ratings

To compare health plans and Medigap policies go to the Medicare website at From the home page, click on “Compare Health Plans.” You can also compare prescription drug plans, nursing homes, hospitals, home health agencies, and dialysis facilities from the website.

In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), the Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data was not available. Almost sixty percent of the Medicare Advantage programs were rated. The rated plans represented 85% of the enrollment for 2009. The report found the following:

  • Private fee-for-service plans and regional Preferred Provider 0rganizations (PPOs) had below average ratings that were significantly lower than traditional HMOs and local PPOs.
  • Non-profit plans had higher ratings than for-profit plans.
  • Plans with contracts that began before 2004 had higher ratings than newer plans.

Part D: Prescription Drugs – The Basics

Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs.

Medicare Prescription Drug Plans are stand-alone plans that add prescription drug coverage to the original Medicare plan, some Medicare Cost plans, some Medicare Private Fee-for-Service plans and Medicare Medical Savings Account plans. To compare health plans and Medigap policies go to the Medicare website at From the home page, click on “Compare Drug Plans.”

Part D is prescription drug coverage provided by private companies. Everyone with Medicare can get this coverage. There is usually a monthly premium for this coverage. If you decide not to enroll in a drug plan when first eligible you may have to pay a penalty if you join later. Part D coverage is not standardized by Medicare. Each plan is free to choose which drugs they cover, what their coverage levels are, and which drugs they don’t cover. If plans cover drugs excluded from coverage by Medicare, they are not allowed to pass these costs along to Medicare.

If you are dual eligible for Medicare and Medicaid, consider that Medicaid may pay for drugs not covered in a Medicaid part D plan.

Medicare Prescription Drug Choices

The decision to get Medicare prescription drug coverage depends on how you intend to pay for your drugs now and how you get your Medicare coverage. Most people with Medicare pay for drugs and get their Medicare in one of five ways:

  • Original Medicare only.
  • Original Medicare and a Medigap policy without drug coverage.
  • Original Medicare and a Medigap with drug coverage.
  • A Medicare Advantage Plan (like an HMO or PPO) or other Medicare Health Plan, which already include drug coverage and other extra benefits.
  • Dual coverage from Medicare with Medicaid drug coverage. These people currently receive comprehensive prescription drug coverage from Medicare.

If you have specific drug needs due to a medical condition, Medicare’s Formulary Finder lets you enter a typical combination of drugs used by people with a certain condition to find out which plans in an area have formularies that cover these drugs.


Joining Medicare

Individuals receiving Medicare benefits have a lot of information to go through.  If you have never enrolled in Medicare and are about to do so for the first time, you too will need a lot of questions answered to make the best decisions. One of the most important tools available is a handbook put out through the federal government called “Medicare and You.” The most recent government handbook can be found at the Consumers can also get a free and secure assessment of their personal Medicare benefits and services at

You can join Medicare every year between November 15th and December 31st. At that time, you can make any changes to your existing coverage.  On January 1st each year your new coverage becomes effective. There are other sources of information in most areas of the country.  Wherever you live, you can get information through your doctor, State Health Department, the Department on Aging, senior centers, or other healthcare or senior organizations.



Medicaid pays for your health care if you are qualified. It is a state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children.

Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. Each state has rules. These rules may be for those in nursing homes. They may be for a child with a disability who lives at home. Usually, a state caseworker will work with you. Most states have programs to help certain people who do not get Medicaid.

Depending on your state, you may also have to pay a small part of the cost. This is called your co-pay. Many groups get Medicaid. You may get Medicaid based on your age, if you are pregnant, if you have a disability, and by your income and resources.

As a general rule, if your income is low and you meet one of the following criteria, your odds of qualifying for Medicaid are good. Criteria include if you are pregnant, or the parent or guardian of minor children, or aged, or blind, or disabled. Many groups of people are covered by Medicaid. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds.

Medically needy persons who would be eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses. As noted earlier, the rules for counting your income and resources vary from state to state and from group to group. There may also be special rules for those who live in nursing homes and for disabled children living at home.

Your child may also be eligible for Medicaid coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not. However, there is a 5-year limit that applies to lawful permanent residents. Eligibility for children is based on the child’s status, not the parents. Your income does not apply to this child. If a person’s child lives with you, he or she may get Medicaid. Apply for Medicaid to find out if you can get it.

People who are eligible for Medicaid may or may not also receive cash assistance from federal programs like the Temporary Assistance for Needy Families (TANF) and/or Supplemental Security Income (SSI) programs. You should contact your state Medicaid office to find out if you are eligible for benefits.  For the most part, you should apply for Medicaid if your income is low and you match one of the descriptions of the eligibility groups in your state, and you or your family needs health care. This will allow a qualified caseworker in your state evaluate your situation.

Remember, Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state’s rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.


Screening Tools – Know Your Benefits

To help you see if you may be eligible for a variety of federal, state, and local programs, you can use the and

When Medicaid Eligibility Starts

Coverage may start retroactive to any or all three months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person’s circumstances change. Most States have additional “State-only” programs to provide medical assistance for specified poor persons who do not qualify for the traditional Medicaid program. No Federal funds are provided for state-only programs.

Low-income Medicaid beneficiaries who would otherwise become ineligible for Medicaid due to an increase in wages or hours at a job are entitled to up to 12 months of Medicaid benefits under the Transitional Medical Assistance (TMA) program.  This temporary coverage increases the likelihood that low-income people who start a job or find higher-paying work will not lose the security of health coverage because they found a job or will earn higher pay.

Working with a Medicaid Case Manager

Family Tips Checklist

If you are getting ready to interview or hire a professional case manager for yourself, a family member, or a loved one, here are some questions you may want to ask during the interview process:

  • How long have you been a Case Manager?
  • How many people are on your case load?
  • Where do you live?
  • How often do you contact each client and their families?
  • How do you communicate with service providers?
  • Do you develop a care plan for your clients?
  • How often do you review and update your clients care plan?
  • What is the best way to contact you?
  • What if is an emergency and we can’t reach you?

Medicaid Planning

There are a few things you can do using Medicaid planning to rearrange finances and legally shelter your assets from the state. The strategies can be very complicated so you may want to consult an elder law attorney to help you with the specifics. You can find qualified Elder Law Attorneys in your area at the National Association of Elder Law Attorneys (NAELA) website which is found at

Medicaid planning helps shelter assets, preserve assets for heirs, and provide resources for a healthy spouse. The total value of your countable assets including your income determines whether you are eligible for Medicaid. Under federal guidelines, each state has a list of exempt assets. This list usually includes items like your home, prepaid burials and contracts, term life insurance, and one automobile.

You can rearrange your finances so that countable assets are exchanged for exempt assets and thus made inaccessible by the state. For example, you can exchange spending your savings on nursing home bills for:

  • Paying off the mortgage on you family’s home.
  • Prepay for burial arrangements.
  • Make home improvements.
  • Purchase one car for your healthy spouse.

Preserving assets for your children and heirs allows you to provide financial help for your loved ones. An irrevocable trust can help you accomplish this. Consult an experienced attorney about how to set this up for your circumstances because “irrevocable” means that you can not come back and change it later or decide to end it. Not to mention, that laws vary from state to state and from year to year.

Property placed in an irrevocable trust will be excluded from your financial picture for Medicaid purposes. Anything that you place into the trust can be sheltered from the state and preserved for your loved ones. More often than not the trust must be in place and funded over a specific period of time for it to be an effective Medicaid planning tool.  You might be able to use an annuity to guarantee that your spouse has enough money to live on if you have to go to a nursing home?

When the state is considering eligibility for Medicaid a couple’s assets are pooled together. Your healthy spouse is generally given a resources allowance amount to one-half of the assets. As you can imagine this may not be much money over the long term especially if your spouse needs to take time off of work.

If you’re married an annuity can help protect your healthy spouse. An important loophole in the current law is that your healthy spouse can use jointly owned countable assets to buy a single premium immediate annuity for their benefit. By doing so, you effectively convert countable assets into an income stream. Each spouse is then entitled to keep all of their own income instead of pooling assets. The end result is that the institutionalized spouse can more easily qualify for Medicaid.

Medicaid Planning Risks

Since laws vary from state to state and from year to year, Medicaid planning is more effective in some states and at certain times than others. For example, when you are applying for Medicaid the state has the right to look back at your finances for a period of months before the application date. Generally, there is a 36-month look-back period for transfers of countable assets, along with a 60-month look-back period for similar transfers into irrevocable trusts.

Countable asset transfers for less than fair market value made during the look-back period will commonly result in a waiting period before you can start to collect Medicaid. For example, transferring your house to your children a year before entering a nursing home may make you ineligible for Medicaid for quite some time.

Without question, you should consult with an experienced Elder Law attorney who is experienced at Medicaid planning in your state. They will be aware of the look-back periods, estate recoveries, possible disqualifications for Medicaid in your state, and all the details you need to be aware of.

FDA Approves New Cystic Fibrosis Treatment

cystic-fibrosis-foundation-logo-e1479836089698Trikafta is the first triple combination (elexacaftor/tezacaftor/ivacaftor) drug therapy approved by the FDA to treat cystic fibrosis. Trikafta is approved for patients 12 and older who have at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene.  The F508del mutation is the most common mutation of over 2,000 mutations of the CFTR gene. According to the FDA, this covers around 90% of U.S. cystic fibrosis patients. read more at


Patient Rights and Protections Under U.S. and State Laws


Last revised: 10/05/2023

Too many times, people give up the fight for their own health and well-being because it’s not always easy. This article helps to clarify the current rights that patients have been granted and are enforced through our federal and state laws.

The patient rights that we hear people refer to most often are the right to…

1. Receive clear and understandable explanations in order to choose a treatment or a course of action based on the available options and their benefits, the risks, the likely outcomes, and the alternatives. This is commonly called Informed Consent.
2. Refuse treatment.
3. Make decisions about end-of-life care.
4. Obtain your medical records, including doctor’s notes, medical test results, and other documentation related to their care.
5. Be treated with respect by providers, practitioners, and payers.
6. Privacy of your medical records; (see HIPAA, 1996).

Let’s start by looking at the key patient rights as guaranteed by Federal law.

Informed Consent

Informed Consent is intended to ensure that a patient can make a well-informed decision about their care. It is a process where a health care provider educates a patient about the benefits, risks, likely outcomes, and alternatives of a procedure, test, intervention, or course of action. At its core informed consent means that a patient must be provided with and understand the information needed to make decisions about their health care; including 1. Their diagnosis, and 2. The purpose, benefits, risks, likely outcomes, side effects, and alternatives of any proposed test, surgical procedure, medical procedure, treatment, or course of action.

Patients also have a responsibility to ask their physician and health care providers to explain what things mean. If a patient does not fully understand the benefits, risks, and likely outcomes of any course of action they need to keep asking for an explanation of what everything means until they do understand. In most cases patients are asked to provide their written consent for any course of action to proceed.

Certainly, there are situations such as emergencies or extremely fragile patients when it may not be possible to get informed consent. In most cases parents can give informed consent for their minor children. Although state laws very and some states do make exceptions for minors to provide informed consent.

Patients must be competent to give voluntary and informed consent. This means having the ability to make an informed decision. Doctors often refer to this ability as having decision-making capacity. To have decision-making capacity a patient must understand their options, the risks and consequences, and the costs and likely benefits of the consequences. Mental illness, mental retardation, alcohol and drug intoxication, altered mental status, brain injury, and age restrictions are all examples that may make a patient incapable to provide their consent.

Refusing Treatment

Patients have a right to refuse treatment in most cases. Exceptions are;
1. Emergencies when immediate treatment is needed for the patient’s safety or to save their life.
2. When patients have an altered mental status due to drugs, alcohol, brain injury, or   illness.
3. Parents can’t refuse life-saving treatment for a minor.
4. When refusal of treatment poses a threat to the community.

End-of-Life Care

Patients have the right to refuse life extending treatment at the end of their life. This right was guaranteed to Americans through the Patient Self-Determination Act of 1991. It requires nursing homes, home health agencies, and others to provide patients with information on advance directives. Advance directives are designed to give instructions on the medical interventions a person wants once they have had emergency treatment. It is usually directed towards the staff at a hospital, nursing home, or home care agency.

A relatively new document called a Physician’s Orders for Life-Sustaining Treatment (POLST) is available to patients with chronic or life-threatening illnesses in some states. A POLST is designed to instruct emergency personnel on what actions to take while you’re still at home.

Your Medical Records

The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), provides individuals with a legal, enforceable right to see and receive copies upon request of their medical and other health records maintained by their health providers and health plans, and to direct the covered entity to transmit a copy to a designated person or entity of the individual’s choice. This includes medical records; billing and payment records; insurance information; clinical laboratory test results; medical images; wellness and disease management program files; and clinical case notes; and other information used to make decisions about individuals. Psychotherapy notes maintained separate from the rest of the patient’s medical record, and information compiled in anticipation or use in a civil, criminal, or administrative action are excluded from this right of access.


HIPAA laws do not keep all others, other than the person, their doctors, and their caregivers, from accessing an individual’s medical records. Individually identifiable records, which contain personal attributes, and aggregated medical records, in which individuals can’t be identified, are both shared and purchased. Under HIPAA laws covered entities have a right to access your medical records if they follow strict rules. Covered entities include doctors, allied medical professionals, facilities, technology providers, payers, and the government.

The general guidelines under HIPAA are;

1. You have a legal right to copies of your medical records.
2. You can designate someone else to get copies of your medical records.
3. Your health care providers have a right to see and share your medical records with others who you given permission.
4. Any payer that pays for a portion of your health care may get a copy and review your medical records.
5. Federal and state government may have a right to your medical records.
6. Companies that keep prescription databases may have information on your prescription drug purchases that they sell to life and disability insurance companies.

Rights in Emergency Departments

Under the Emergency Medical Treatment and Active Labor Act of 1996 (EMTALA), you have a right to emergency care if you are in any incident that is life-threatening or sever, or where bodily functions or organs are seriously impaired, or any incident where delivery is imminent in a pregnant woman. Under EMTALA emergency departments (ED) must:

1. Provide a screening examination.
2. Stabilize anyone with an emergency medical condition.
3. Arrange for transfer to another facility if the ED can’t stabilize you.

You cannot be turned away because you can’t pay. Although, you are responsible for the full bill, even if you don’t have health insurance. There are many ways to work out payment arrangements, including charitable care. If you go to an emergency room for a non-life-threatening prenatal care, wellness checks, health screenings, follow up, doctor visits, or non-life-threatening conditions such as flu, fever, colds, rashes, sore throats, etc., you do not have a right to care.

Other Federal Laws

The Patient Protection and Affordable Care Act (ACA) of 2019

The Affordable Care Act includes a Patient Bill of Rights (PBR) that gives Americans the following protections:

a. Section 1557 prohibits discrimination in the basis of race, color, national origin, sex, age, or disability in certain programs and activities. Section 1557 also extends protections granted under Federal civil rights laws, including, (Title VI of the Civil Rights Acts of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975) to individuals participating in 1. Any U.S. Department of Health and Human Services (HHS) funded or administered program or activity, and 2. Health Insurance Marketplaces and all plans offered by issuers participating in those Marketplaces.
b. Requires insurance plans to cover people with pre-existing conditions, including pregnancy, without charging more.
c. Free preventive care.
d. Ends lifetime and yearly dollar limits on the coverage of essential health benefits.

The Stark Law

The purpose of this law was to curb physician self-referral, or referring patients to hospitals, labs, home health services, medical equipment and devices, therapy. Lab, and other entities or services
from which they or a family member, benefit financially.

The Anti-Kickback Statute

This statute prohibits transactions intended to induce or reward referrals for items or services reimbursed by the federal health care programs. The statute is designed to protect federal program health beneficiaries from the influence of money on referral decisions.

The Health Information Technology for Economic and Clinical Health Act (HITECH)

The HITECH Act was enacted as part of the American Recovery and reinvestment Act (2009) to promote the meaningful use of health information technology by incenting health care providers to adopt electronic health records and adopt privacy and security protections.

The Genetic Information Nondiscrimination Act (GINA) of 2008

GINA protects Americans from being discriminated against based on their genetic information in health insurance and employment.

State Laws

Many states have enacted laws on the use, collection and disclosure of health information. Some states even detail what each person’s medical record must include. States have also set standards for privacy and confidentiality that often exceed federal laws. Others have set standards for how private health insurers conduct business within their state. For example, because Medicaid is a partnership between the federal government and the states, many states have passed their own regulations on participating providers.

Surprise Medical Bills

Surprise medical bills often occur when someone is treated in an in-network hospital emergency department or facility by out-of-network physicians or other health professionals. As of mid-2019 twenty-eight of the states had enacted consumer protections. As of mid-2019 only thirteen states had protections that limited the consumer’s financial exposure, extended protection to both hospital emergency departments and in-network hospital settings, applied to both HMO and PPO members, prohibited balance billing, and adopted a payment standard or process to resolve payment disputes between providers and payers. The Commonwealth fund as provided an interactive map that reviews the Balance-Billing protections for each state.


Many patient rights are rooted in the American Medical Association (AMA) Code of Medical Ethics. The AMA Code of Medical Ethics guides physicians in their patient and physician interactions, treatments & use of technology, and in their professional relationships and self-regulation. The Patient Bill of Rights (PBR) details each patient’s rights and responsibilities to help improve the quality of your care.

National and state health care laws are changing. It’s important to research the latest laws when you have an issue with your payers, providers, or doctors. We will attempt to update this article as new information becomes publicly available. However, when you have an issue a healthcare attorney in your state should be consulted to ensure that you know the latest federal and state laws.

Patient Guideline: Finding the Right Doctor

By W. Kolber, MHA

The relationship that you have with your primary doctor is possibly the biggest factor in determining the quality of healthcare you get in the U.S. Without the “right” primary care doctor you are left without what may be your best advocate. You can find “Dr. Right” with effort, and it’s well worth it. Just, don’t expect it to be easy.  

The “right” doctor for you will;

  1. Listen to you.
  2. Treat you with respect.
  3. Communicate in a way that works for you.
  4. Help coordinate your healthcare needs and doctors.
  5. Be available when you need her/him.
  6. Be aware of what matters to you.
  7. Be in your health insurance network; if you are insured.

Remember, the “right” doctor for you may not be the right doctor for someone else. Finding the right doctor involves putting together information from many different sources.

Sources include;

  1. Your insurance provider.
  2. Your personal observations when you visit.
  3. Other doctors and health care professionals.
  4. Friends and family.
  5. The Internet.
  6. Other patients.

This article guides you through the process, helps you evaluate the information you get from others, and tells you the questions to ask. 

Step 1

The first decision you should make is who will be your primary care physician.

In an ideal situation this is the doctor who will help you make the right choices based on your medical situation and your preferences. If you are in an HMO, your primary physician will be required to manage your referrals to specialists. Even if you’re not in an HMO you will want your primary doctor to do the following;

  1. Know who you are.
  2. Know what you want.
  3. Coordinate your healthcare.
  4. Explain things you don’t understand.
  5. Connect you with other providers and services.
  6. Advise you about anything on your mind related to your health.
  7. Be accessible when you need help.

Now that you know what your doctor should do, consider the qualities you want. A few key qualities to consider include;

  • years of experience.
  • education background; including their residency.
  • male or female.
  • convenience of practice; location and hours.
  • after hours access to help.
  • communication methods; phone, email, text, etc.
  • designation as a medical home.

The “medical home” practice model is a team-based model. The doctors who follow the principles of the patient-centered medical home model take the lead for each patient’s medical team, while the team collectively takes responsibility for providing the patient’s health care needs. In 2007, several of the leading medical organizations, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association released the “Joint Principles of the Patient-Centered Medical Home.

The principles are:

  • Each patient has an ongoing relationship with a personal doctor trained to be the primary contact. That doctor provides continuous and comprehensive care.
  • A personal doctor leads a team of individuals at the practice who collectively take responsibility for the ongoing care of each patient.
  • A personal doctor is responsible for providing all the patient’s health care needs, or taking responsibility for appropriately arranging care with other qualified professionals.
  • Care is coordinated and/or integrated across all providers including specialists, hospitals, home health agencies, nursing homes, etc.
  • Quality and safety are enhanced through care plans, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, information technology, and quality improvement activities.
  • Patients have open access to care via email, flexible scheduling, convenient hours, telehealth, quick and effective communication, and other means.
  • Payments should reflect the value of the work that is done both inside and outside of the face-to-face visit.

Step 2

Identify three to five doctors in your insurance network that meet your criteria by using your health insurance Provider Directory. Find the type of doctor that meet your needs. The most common primary physicians are Family Practice, Internal Medicine, General Practice, and in some cases for women OB/GYN. If you don’t know how to access the Provider Directory call your health insurance customer service number.

Step 3

Review the qualifications of each physician. The medical credentials such as the medical school a doctor went too, and where they did their residency often indicate how well a doctor performed during their early training. A doctor’s credentials may also show you if a doctor has achieved a level of expertise and knowledge that the Medical Board that oversees their specialty feels qualifies that doctor for certification.    

Often these basic qualifications can be checked in your health insurance provider’s handbook or on their web site as a part of the listings for the doctors who are in their network. There are also many web sites that offer this information about doctors. Some of the leading websites for physician ratings and reviews can be found at www.aPatientsPlace,com. One of the best sources outside of your insurance provider is the professional medical association that licenses, certifies, and supports the doctor’s practice specialty. Another great source is the web site..

You can check if your doctor is Board Certified at the web site There is no cost to register, and you can look up as many as five doctors each day. Board certification means that the doctor has completed an approved residency program and passed a detailed written exam in at least one of 24 specialty areas, such as family practice, internal medicine, or obstetrics and gynecology. Most doctors must renew their certification every five or ten years. Sometimes older doctors do not need to renew their certifications due to rules that cover experienced doctors. If the doctor is not board certified, find a different doctor.

Another simple way to find a doctor’s basic qualifications and a little about their practice at the same time, is to call their office and ask their staff.

If the doctor or their staff is hesitant to answer your questions, if their phones are not answered quickly, or you are put on hold for more than a few minutes, you should think about how you would feel if you were their patient and the same things were happening to you.

Tip: Start building a relationship with your doctor ASAP. Consider that a typical primary care physician may have 2,000 to 3,000 patients, and they may see as many as 30 patients on busy days.

Step 4

Contact the practice by phone.

Here are some questions to ask the practice administrator or the receptionist during your initial phone call…

  • Is the doctor taking new patients?
  • Do you accept my insurance?
  • How long does it usually take to get an appointment?
  • How long does the doctor usually spend with each patient during an appointment?
  • Can I get a same day appointment in an emergency, or if I am in pain?
  • What are the office hours?

If the practice receptionist has the time, additional questions that you might ask include;

  • Who will see me when the doctor is not available if I have a problem, question, or concern?
  • Is the doctor part of a group practice? Where can I get more information about the other doctors?
  • Which hospitals does the doctor use?
  • What is your cancellation policy?
  • Is lab work done in the office, or at an off-site facility?
  • Do you help patients with their insurance claims?

Step 5

Check for Criminal Conduct. You can look this up on the web at That site lists each individual state’s medical board site. There you can search under professional misconduct to see if your doctor has been listed. You might be surprised by what you find. You might also consider checking the federal government’s Open Payments database to see if their doctors receive payments from drug makers or medical device manufacturers. 

Step 6

Check the Doctor’s Reputation. There are several ways to check a doctor’s reputation. Remember though, that another patient’s experience, or a list of “top doctors” may not be based solely on facts. Information from patients, other health professionals, and subjective sources should be confirmed by at least two other sources if possible. Here are some ways to find more about your doctor’s reputation:

  • Ask the doctor’s current patients. When you are waiting to see the doctor, talk to a few other patients in the waiting room. Tell them that you are a new patient, and ask them what they like most and least about the doctor and practice.
  • You can also learn about a doctor’s reputation from other health care professionals.
  • If you prefer, you can look online at the growing number of web sites that publish information from patients and health care professionals about their experiences with specific doctors. The web site Yelp is one such example. A more complete list can be found at
  • You can also search for “patient chat rooms” or “patient referrals” in your local area using your favorite Internet search engine. Sometimes, local magazines and web sites even publish lists of your area’s “best doctors.” Although, being listed as a top doctor in a publication or on a website does not necessarily mean that they are a good doctor.

The best doctor to work with will be open and honest about his or her limitations. A doctor’s attitude towards patients who would like a second opinion does not provide insight about the reputation of the doctor. It does show a lot about their comfort for recognizing that their patients are at the center of the health care system. Good doctors will welcome another opinion. If they are unwilling or resistant to refer their patients to other specialists this may be a sign of arrogance, or caring more about their ego than the well-being of the patient.

Some hospitals and health providers have phone or online doctor referral services. Usually you can find out if your hospital or health system has such a service simply by calling their main number or going to their web site.

Tip: Do not call 800 numbers at the local hospital as your only source during your search for a doctor. Many hospitals and health systems use these services to influence you to choose the doctors who drive the most revenue to the hospital, or to help a new practice add patients, or increase the use of a new treatment.

Step 7

Ask for Referrals. Since the early days of medicine, referrals have been one of the primary ways that people learned of doctors who might help them. Referrals from someone you trust gives you the advantage of learning from someone else’s experience. The most likely sources for referrals are health care professional, nurses, your family, a friend, a neighbor, or a co-worker. Consider though, that the experience of the person referring the doctor to you may not be similar to what you experience.

Tip: The fact that the person giving you a referral had a positive experience, or that they have been using the same doctor for  many years does not mean that they are getting good care, or that you will.

There are also web sites that are set up by other health care professionals to help people find doctors. Examples are and There are also social networking sites like Yelp that let users post and read comments about local doctors and practices. One of the challenges with online reviews is that you can’t always be certain that the reviews are authentic, or that they aren’t written by friends. Not to mention that patient reviews are often only written by people who either hate or love their doctors.

Step 8

Consider Ratings. Health insurance companies have been rating the performance of doctors for years, but consumers seem to prefer the opinion of their peers over a company that might have a financial interest in their ratings. Information and ratings from insurance providers and hospitals may also be influenced by the financial goals of the organization.  Some experts feel that ratings tend to influence patients to see the least expensive instead of the best doctors. However, if your insurance provider web site tells you how many procedures a doctor has done or other facts about the doctor that can be very helpful information.

Tip: Patient chat rooms and discussion groups can be an excellent source of referrals and information for everything from doctors to nursing homes to therapists. There are many patient chat rooms available at

Step 9

Schedule an “Interview” Appointment. Meet and talk to every doctor, or at least their Practice Manager before trusting them with your treatment and/or care. Most practices have set aside a few time slots for new patients to come in and speak with the doctors. You might want to think through some of the following questions before scheduling an interview appointment.

  • Where is the practice located?
  • Will it be easy for you to get there?
  • Is it accessible by public transportation?
  • Is there ample parking?
  • Which hospital(s) does the doctor use?
  • Are you comfortable with the possibility of being treated at one of these institutions should the need arise?
  • Where are routine x-rays and laboratory studies performed? Can these be done in-office, or will you have to go to an outside laboratory?
  • How long must you wait for an appointment after you call? Can you be seen on the same day if you have an urgent need?
  • Is the office staff friendly and courteous?
  • If you call with a question about your care, does a doctor or nurse return your call promptly?
  • Who covers for the doctor when he/she is away?
  • Whom should you call if you have a problem after-hours?
  • If the doctor works in a group, are you comfortable with being seen by one of the practice partners?
  • Does the doctor frequently refer patients to other specialists, or does he/she prefer to manage the majority of your care?
  • Does the office process insurance claims, or must you pay up-front for services and file the claims yourself?
  • How long will you have to wait for an appointment? Look for practices that offer “open-access” scheduling, in which doctors typically leave part of each day’s schedule un-booked so they can offer some same-day appointments.
  • Do they keep paper or electronic medical records? Computer-based record-keeping is considered a major step toward improving the quality and efficiency of medical care. But not all doctors use electronic records.
  • Do they take questions by secure e-mail or text? E-mail “conversation” is great for problems or advice about a chronic disease, an appointment, test results, clarification of some item that came up during an office encounter, an overlooked question, a medication side effect, or any question requiring only a yes or no answer. And it’s a direct link to your doctor, without a telephone intermediary such as a nurse or assistant and can supplement your time with you.

During your initial appointment, you want to consider if the doctor …

  • Communicates openly and honestly.
  • Encourages you to ask questions.
  • Listens to your opinions and concerns.
  • Answers your questions.
  • Is not defensive.
  • Has experience treating your medical condition successfully.
  • Will spend the right amount of time with you.
  • Respects your preferences.
  • Explains things in way that you are comfortable with.

You should always work with a Board-Certified doctor. This means that they have completed residency training in a specific field following graduation from medical school, and they have passed a competency examination in that field.


  • Contact your insurance provider to discuss your options, and get an updated copy of your insurance plan benefits.
  • Check each doctor’s qualifications.
  • Make sure the doctor accepts your insurance. Why pay yourself if there is an excellent doctor in your insurance provider’s network?
  • Disregard advertisements.
  • When your doctor refers you to a specialist, always ask for two different recommendations.
  • Don’t wait in an office for more than an hour. Having to wait for hours may mean the doctor is under-staffed.
  • If you have no insurance or only have Medicaid, go to a clinic at a university medical center.

Here’s a link to additional information on working with doctors.

Suggestions When Having a Breast Biopsy

By Helen M. French, BSN, ADN/RN, an operating room nurse to whom ALL life is precious.

BREAST CANCER SURGERY: PLEASE, take note of several critical suggestions, I have for any “woman or man” who is having a “breast/s biopsy”: As simply as I can state the “surgical aspect/s”: If a biopsy is being done just on ONE breast, suggest/request that your “surgeon” ONLY does the “BIOPSY” and then waits for a “permanent” tissue result, which will only take the lab 2 or 3 days. It is my opinion, that a “frozen” biopsy, i.e. a quick lab result, which usually takes about 45 minutes, has more of a chance of producing a “false positive”. The “argument”, that is often exposed, is that YOU will have to come back for a second procedure, etc etc, BUT, in my opinion, as an operating room RN, who has “circulated and/or scrubbed” on many breast cancer cases and mastectomies, I believe that it is worth the hassle. It is very possible that the “first” specimen i.e. the one under going a “frozen” test, could be incorrectly read/diagnosed by the lab tech/pathologist or even “mixed up” with someone else’s breast biopsy/tissue. Please ,also remind your surgeon that the “specimen”, whether IT is going to the lab as a “frozen” or one that has been placed into a jar of “formalin per the doctor’s orders, while in the OR room, that IT is CLEARLY marked with “ones name/with middle initial, date of birth, medical number as well as their “surgeon’s name”, along with the actual date of the procedure and the “location of the specimen”; IF the “OR” is using their hospital labels, the information on the label still has to be correct. # Secondly, CONFIRM with YOUR OR RN Circulator and with your surgeon, before surgery the “correct” breast IF just ONE is being operated on. Even though, the OR RN Circulator, the surgeon and the entire OR team is to “verbally confirm the “correct site” of any surgical procedure, before making any incision, if I was the patient, I would mark the “correct” breast with an ink pen that does not wash off. # Thirdly, a very critical issue, but not the end, IF IF IF one is having a biopsy on both breasts, I stand by my “preceding remarks”, BUT, also mention to the surgeon before hand, to make sure that “TWO” mayo trays are “set up/being used” by the “scrub person”!!! I.E. ONE “mayo tray” for the “right breast” and ONE “mayo tray for the “left breast”. NEVER should just ONE “mayo tray”, on which, the scissors, forceps, mono-polar cautery, sponges, etc are on, ever be used on “both”. IF, there are cancer cells in any of the specimens taken, cancerous cells can be transferred over to the “side” which has NO cancerous cells. (I.E. pic is a generic image of breast cancer cells); Dear Facebook readers, be safe, blessings, frenchie i.e.