how much did you spend during your interaction with each provider approached before you were diagnosed with TB till the time of receiving the TB treatment?/ About how much did you spend during your interaction with each provider that you approached since the onset of your chest symptoms? ( For all that don’t apply, mark N/A; Fill one line per visit) Type of No. of Total Time Test costs X ray or Drug costs Travel Food costs Sub-Total Insurance Provider visits spent per Costs (for sputum other imaging (all kinds total Costs (if – costs per (provider visit test (e.g. CT an (G)] applicable) or TB plus other provider code) (in hours, scan) costs an (G)] (total) (If yes: except x drugs such as E1_B (includes (return total) amount, includes registration) E1_K ray) cough syrups, E1_A (G)] if no n/a) sending x rays travel time) vitamins) (total) to radiologist, E1_D E1_E E1_L E1_C travel & fees) E1_G P G P G P G E1_F E1_H1 E1_H2 E1_J2 E1_I1 Provider 1 Provider 2 Provider 3 Provider 4 TOTAL Total Direct Pre-diagnostic& Diagnostic costs (sum sub-totals) minus insurance [E1_M] =
how much did you spend during your interaction with each provider approached before you were diagnosed with TB till the time of receiving the TB treatment?/ About how much did you spend during your interaction with each provider that you approached since the onset of your chest symptoms? ( For all that don’t apply, mark N/A; Fill one line per visit) Type of Provider (provider code) E1_A No. of visits E1_B Total Time spent per visit (in hours, includes travel time) E1_C Costs registration) E1_D Test costs (for sputum or except x ray) E1_E X ray or other imaging test (e.g. CT scan) costs (includes sending x rays to radiologist, travel & fees) E1_F Drug costs (all kinds total – TB plus other drugs such as cough syrups, vitamins) E1_G Travel (G)] (return total) Food costs (G)] (total) Costs (if applicable) (G)] (total) Sub-Total costs per provider E1_K Insurance (If yes: amount, if no n/a) E1_L P E1_H1 G E1_H2 P E1_I1 G P G E1_J2 Provider 1 Provider 2 Provider 3 Provider 4 TOTAL Total Direct Pre-diagnostic& Diagnostic costs (sum sub-totals) minus insurance [E1_M] = an an
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