Financial Worksheets - Do you use them and if so, are they an effective tool?

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My center is working on presenting patients with a Transplant Financial Worksheet. (I have copied a version here - so you can have an idea of what I'm talking about - I hope it comes through on your end) I am curious though, if any other centers use a form similar to this. If so ...

Do you complete this with the patient, or simply give to them to use as a personal tool?

Have you found this to be effective post transplant or even pre-transplant, (as a way to assess financial needs/concerns before evaluation begins)?

If you use something like this, do you find that patients appreciate this or simply blow it off?

Any input you have, or any forms you have and use would be greatly appreciated! You can email me directly if you'd wish: jduran@... Thank you in advance for your help, experience and suggestions!!

-Jacqui Duran, Liver Transplant Financial Coordinator

Saint Luke's Hosptial of Kansas City | 4401 Wornall Rd, Kansas City, MO 64111 |

This worksheet is a tool for you and your Transplant Team to help you with your financial planning in regards to your potential transplant. It is imperative that the information you provide is as accurate as possible, as this is what we need to know to be able to make this affordable for you and not to be a burden on you. If your financial status changes, please bring it to the attention of your Transplant Financial Coordinator as we can work to find ways to help you.

Monthly Income

Monthly Income $_________________ Total Household Income: $________________

Source: __________________________________________

Spouse Monthly Income $_________________

Source: __________________________________________

Other Income: $_________________

(child support, SSDI, alimony, etc)

Source: __________________________________________

Monthly Expenses

Rent/Mortgage $_________________ Total Expenses: $_______________

Utilities:

Gas $_________________

Electric $_________________

Water $_________________

Trash $_________________ Balance Card:

Total Household Income

$

Total Monthly Expenses

-$

Total

$

Phone (Cell) $_________________

Internet $_________________

Other $_________________

Insurance:

Auto $_________________

Health (spend down) $_________________

Dental $_________________

Vision $_________________ Take the Total here and insert it below:

Total Income after Expenses

$

Approx Cost of Immunosuppression medications

-$

Total

$

Life $_________________

Loans:

Auto (Car, Boat, etc.) $_________________

Student Loans $_________________

Personal $_________________

Credit Card Payments:

#1 ____________________ $_________________

#2____________________ $_________________

#3____________________ $_________________

Monthly Expenses:

Food & Groceries $_________________

Maint/Repairs (home, car) $_________________

Childcare $_________________

Clothing $_________________

Current Medication Costs $_________________

Other expenses:

#1____________________ $_________________

#2____________________ $_________________