ࡱ> y bjbj 7J{{=8($L~p$">`)0vB<~f#f#f#-~f# :  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: __Right Ovarian Mass___________________________ Date of Diagnosis: ______08/07/2008____________ Comments: __Rule-out ovarian cancer, has finding suggestive of ovarian cancer and needs to obtain diagnosis.______________ _______________________________________________________________________________________________________ Treatment Plan from _09/2008__ to _01/2009__ Primary Treating Physicians Name: ________Dr. Dolittle_____________ (date) (date) Procedure and Frequency of TreatmentDate AnticipatedEstimated Costs Basis for costs (Medicaid rate, HSCRC-regulated rate, or MHIP rate)Pelvic and transvag ultrasound09/2008562HSCRCXray interpretation09/2008116MedicaidLab: CA 12509/200866HSCRCGyn oncology consult10/2008149MedicaidCT pelvis and abd10/20081000HSCRCRad reading of ct10/2008452MedicaidExploratory lap, tumor debulking10/20082122MedicaidAnesthesia11/2008200MedicaidInpatient pharmacy11/2008500HSCRCInpatient lab11/20081000HSCRCHospital room x 2 days11/20083000HSCRCOR x 2 hours11/20083000HSCRCInpatient surgeon visit11/200850HSCRCOutpatient pharmacy12/2008-08/20091000MedicaidOutpatient lab12/2008-08/2009500MedicaidOutpatient medical onc consult12/2008588MedicaidChemo01/20095695MedicaidFollow up medical onc consultSub Total for Treatment20000Indirect costs (Maximum of 7%)$1400Total Requested (Treatment + Indirect)$21,400     Sample E Form DHMH 4684 (Revised 03/31/2013)  %&'cz + ^ _ ` v ~ N Z [ \ r s t y źũxxxoe^eo h>*CJhhXC>*CJhhXCCJhhx>*CJhh >*CJhhF>*CJhh]Dj>*CJhh]DjCJ h 7CJhhc5CJaJhhdfCJaJhhZ(KCJaJhh 7CJaJh+2CJaJh CJaJ(jhEH[h+25CJ OJQJUaJ $&'  u v [ \  # 4 D x $Ifgdc5 $IfgdZ(K $Ifgd gdXCgd]DjgdZ(KgdZ(K x y     = B C D b j k l ɿ hT_CJhhT_6CJ h  CJ hT_6CJhh 6CJhh  6CJhhV6CJ hiCJ hi5CJ hZ(KCJhh]DjCJhhXCCJ h>*CJhhXC>*CJ6x y d[[[[ $IfgdZ(Kkd.n$$Ifl\t"81b 04 layt d[[[[ $IfgdZ(Kkdn$$Ifl\t"81b 04 layt d[[[[ $IfgdZ(Kkdvo$$Ifl\t"81b 04 layt     d[[[[ $IfgdZ(Kkdp$$Ifl\t"81b 04 layt  0 8 = C d[[[[ $IfgdZ(Kkdp$$Ifl\t"81b 04 laytC D V ^ b k d[[[[ $IfgdZ(Kkdq$$Ifl\t"81b 04 laytk l d[[[[ $IfgdZ(KkdZr$$Ifl\t"81b 04 layt d[[[[ $IfgdZ(Kkds$$Ifl\t"81b 04 layt d[RRR $IfgdZ(K $IfgdFkds$$Ifl\t"81b 04 layt  1 6 7 8 R W X Y | +345VWopvx崬h9h hVajhVaUhdlhT_56CJ hT_5hc5hT_5hhT_56CJhT_ hT_6CJ hT_CJhhT_6CJhPhT_6CJ?   d[RRR $IfgdZ(K $IfgdFkdt$$Ifl\t"81b 04 layt $ , 1 7 d[[[[ $IfgdZ(KkdZu$$Ifl\t"81b 04 layt7 8 E M R X d[[[[ $IfgdZ(Kkdv$$Ifl\t"81b 04 laytX Y q y | d[[[[ $IfgdZ(Kkdv$$Ifl\t"81b 04 layt _VMVV $IfgdF $IfgdZ(Kkdw$$Ifl\t"81b 04 lagҲyt/o _VVVV $IfgdZ(Kkddx$$Ifl\t"81b 04 lagҲyt/o  _VVVV $IfgdZ(Kkd.y$$Ifl\t"81b 04 lagҲyt/o&+4_VMMM $IfgdZ(K $IfgdFkdy$$Ifl\t"81b 04 lagҲyt/o45STUV_VVVV $IfgdZ(Kkdz$$Ifl\t"81b 04 lagҲyt/oVWopvw_VMMM $IfgdZ(K $IfgdZ(Kkd{$$Ifl\t"81b 04 lagҲyt/owx4+" $IfgdN $IfgdZ(KkdV|$$Ifl\t"81b  (04 lap(yt+kd[}$$Ifl\t"81b  (04 lap(yt $IfgdZ(K $IfgdZ(K $IfgdZ(K4/---gdN kd`~$$Ifl\t"81b  (04 lap(ytgdN $a$gd  hdlhVahh CJaJh CJaJh 51h0:p= /!"#$% .nDdP%AZ  C 6AMDcancerFund7bRm`<$D y}\mDFTm`<$D y}JFIFC    #%$""!&+7/&)4)!"0A149;>>>%.DIC;C  ;("(;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;X" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?(;oZUolG,n49\iE-&<~9 WWq=4ӦaǙk3VF*5Z 2N}?KԼ]"1x|?m&DGkݦ-~\sjqؿQx<=jO}{xu|SDӬLш]p?M!\Y[oΌg$yɹ 5Wݟ8{e"b0XuOJ={_ToW"הT+վ(ȱ~'5/͞?FZK|7$-?ѫ gmj,)QER-p,5uOq!F*e%voBJ䦮=Ś|}deлvpv2;sZm'S/-RD8[xMsz p+G{?E w\F!$8x':oO ۚo!Ə_V|Mۏ jg.Ȯgtv HE&{sW?Vjpۚo!Ə_Th=;#׾]xvKgqxW,@؜dMvu'fE]z|V=%]Š( (((((((((((((((((((((((((((((((((((((((((((((((((((((5+Q馿4<35[ÚZO׾ׁk??#]?Dsf_ Mǚ)?QWk+/6SXCA#yѺs@'+j$r(theaFzqt(PkQKN*5*Tz3S_oc}}),U89t]CEoOe_z ^׳ζi +@_*Uҿe^"WߩQQbOkվ(ȱ~'59/͞?_O,m7э_0W t<1[ű(Ϙs^ēni+7,<=7cۀ?:Go G#¹'vfMSEh;+^ %ol(8=sNܝiЧϿ#or:ƶek\^ϩj7w3O+I!lI+ghm!`~keMK;t( ( ( ( ( ( ( ( (35mQtIwӂFtψ|E5wڬH:pxPW2[$6ԍK1=50Y6p{w\tIQV[kשummI,a#<?Y<&Š(AEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPm97k'c>,'7ӯ~\\Ѻ$4Rщ!{Tkt_:}JQ \in-";7jڌr##@2wB)14ʛ: gK4zUEsio{[A7TAMt{_stR \sD9Epqֻ+MFnl#&sϡ>ƼB7?4ZG/ xob:G/Rz>(ȱ~'~%񞄺dz{]`Hs ARAוѕ >{1U*s`kfwyYk 0c~;txz'|MwN&$|R 'z◽_N?b$O?]u'؏Ꮘwڏ!UmFUj I'{ץTBՈQ/1?G*; 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