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Lloyd tan trust fund

LLOYD TAN TRUST FUND
APPLICATION FORM
For Financial Assistance to Undergo DBS Surgery

SECTION A
Parkinson’s Patient (please attach a photocopy of NRIC)


Name: ……………………………….
NRIC No.: ………………………………… Date of birth: …………………….…. .…….……………………………………… ……………………………………………… ………………………………………….…. ……………………………………………… Email address: ………………………………………… Tel. no.: ……………………….……… Fax no: ………………………………
SECTION B
Financial Condition (please attach relevant salary slips and income tax returns)

Patient’s Occupation: Retired / Working (specify): ….………………………….….
Net monthly salary/pension: RM……………….…… If working, name of Company: …………………….……………. HR person & tel. no.: …………………………………………….… Name ……………………………………….………………….……. Occupation ……………………….………. Net monthly salary/pension: RM……………………. If working, name of Company: …………………….………………. HR person & tel. no.: …………………………………………….… Is the Parkinson’s patient providing financial support to dependants? Yes/No
If yes, please list all the dependants below:
Name
Relationship
Occupation
(If the space above is not sufficient, please provide information in a separate paper)

Does the Parkinson’s patient have any working children? Yes/No
If yes, please provide full details of working children below:
Name
Age Occupation Married?
Dependants
Occupation
(If the space above is not sufficient, please provide information in a separate paper)

Is the Parkinson’s patient taken care by Caregivers other than spouse/children?
Yes/No
If yes, please provide full details of Caregivers below:
Name
Age Occupation Married?
Dependants
Occupation
(If the space above is not sufficient, please provide information in a separate paper)

Are there any other relatives, friends or external bodies (government welfare,
church, charity body, etc.) who are contributing financial support? Yes/No
If yes, please provide full details of other contributors financial support below:
Relationship
Monthly amount (RM)
(If the space above is not sufficient, please provide information in a separate paper)
In order to determine whether the Parkinson’s patient fulfills the Significant
Financial Constraint
criteria, please fill up the calculation table below:

Net monthly salary/pension of Parkinson’s patient
plus Net monthly salary/pension of spouse minus Monthly total of Parkinson’s patient’s medical expenses minus Monthly expenses of dependants of Parkinson’s patient minus Monthly cost of living for Parkinson’s patient & spouse Net total monthly savings/deficit of Parkinson’s patient
Note: If Parkinson’s patient/spouse have no income, provide total monthly cost of
expenses in line A above (as minus sign, showing a net deficit).

#1 Child of Parkinson’s patient:
plus Net monthly salary/income of spouse minus Monthly expenses of dependants of #1 Child minus Monthly cost of living for #1 Child & spouse #2 Child of Parkinson’s patient:
plus Net monthly salary/income of spouse minus Monthly expenses of dependants of #2 Child minus Monthly cost of living for #2 Child & spouse #3 Child of Parkinson’s patient:
plus Net monthly salary/income of spouse minus Monthly expenses of dependants of #3 Child minus Monthly cost of living for #3 Child & spouse (If the space above is not sufficient, please provide information in a separate paper)
#1 Caregiver of Parkinson’s patient:
Net monthly salary/income of #1 Caregiver plus Net monthly salary/income of spouse minus Monthly expenses of dependants of #1 Caregiver minus Monthly cost of living for #1 Caregiver & spouse Net total monthly savings of #1 Caregiver (If the space above is not sufficient, please provide information in a separate paper)
Total monthly amount from other contributors of financial
TOTAL NET MONTHLY SAVINGS (A + B + C + D + E + F)
If more than RM4,000,
disqualified from applying for
financial assistance. Not required
to submit this application form.
Declaration by Applicant
(Applicant can be Parkinson’s patient, or immediate family member or Caregiver)

I, ……………………………………………., NRIC No.: ………………………………,
hereby acknowledge that I have read and understood all the terms and
conditions of this application, as set out in Schedule I of this form and hereby
declare that all the information provided above are true and accurate.
I hereby declare that the Parkinson’s patient in this application form has never
undergone the Deep Brain Stimulation surgery or any other type of brain surgery
as a specific treatment for Parkinson’s Disease (e.g. pallidotomy).
I hereby declare that the Parkinson’s patient in this application form has
exhausted all means in obtaining financial assistance from his/her present or
previous employers (regardless of governmental or private organizations).
Relevant documents are attached to support this.
I hereby declare that the Parkinson’s patient in this application form is
Independent from any of the members of the Working Committee appointed by
HSBC (Malaysia) Trustee Berhad, the Neurologist (in Section C below) and the
hardware supplier, Medtronic Inc. group of companies.
Save and except for the additional information below, I declare that there are no
other information that have been omitted, which if such information were
included, would have provided a significantly different view of the financial
condition of the Parkinson’s patient:
…………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………….
…………………………….……… If Applicant is not the Parkinson’s patient, please describe your relationship with the Parkinson’s patient: …………………………………………………………………………………………… Correspondence address: …………………………………………………………… …………………………………………………………… Tel. no.: ……………… Fax no.: ………………… Email address: ………….…. SECTION C
Medical Report (to be completed by Neurologist)

Onset of symptoms (year): ……………
When was the diagnosis made (year): ……………
Disease duration (years): …………….
Current medications:
Name
Strength
Total daily no. of tablets

Significant response to medications: Yes/No

Motor complications:
“Wearing off” phenomenon Yes/No
“On and off” phenomenon
Minimally disabling / Moderately disabling /
Severely disabling


Impairment in quality of life:
Severity of impairment
Moderate

I, Dr ……………………….……………., NRIC No. …………….…………… hereby
acknowledge that I have read and understood the Protocol for DBS surgery as
set out in Schedule II of this form and hereby declare that, in my opinion, the
Parkinson’s patient in this application form has fulfilled ALL the inclusion and
exclusion criteria for DBS surgery. I declare that I am Independent from the
Parkinson’s patient in this application form.

…………………………………………….
…………………………….……… Correspondence address: …………………………………………………………… …………………………………………………………… Tel. no.: ……………… Fax no.: ………………… Email address: ………….…. Schedule I
Terms and Conditions of Application for Financial Assistance

Eligibility criteria

Qualified Parkinson’s Patients means Parkinson’s Patients, who have been assessed and
confirmed by the Working Committee appointed by the Trustee and an Independent Neurologist,
to have all of the following features:-
(a)
*advanced stage of Parkinson’s Disease (at least ten years of disease duration); fulfill ALL the inclusion and exclusion criteria for DBS surgery; Malaysian citizens or permanent residents; have never undergone the DBS surgery or any other types of brain surgery as a specific treatment for Parkinson’s Disease (e.g. pallidotomy); posses the documents that unequivocally show that they have exhausted all means in obtaining financial assistance from their present or previous employers (regardless of governmental or private organizations); and Independent from any of the members of the Working Committee appointed by the Trustee, Neurologist, Neurosurgeon and hardware supplier. *An exception is the relatively young Parkinson’s Patients (aged 50 years or less), whose career is significantly impaired, and who also fulfill all the criteria from (b) to (g) above, but not necessarily criterion (a).
Terms and conditions

Each Parkinson’s Patient is eligible to receive financial assistance from the Lloyd Tan Trust Fund
only for a total of two occasions (the first brain surgery when the electrodes and pulse generator
are implanted, and the second surgery when the pulse generator is replaced).
The Lloyd Tan Trust Fund will not pay any other costs pertaining to medications, doctors’ medical
fees, hospitalisation, accommodation, any form of complications of the DBS surgery or
complications of the replacement of the pulse generator and other incidental costs required to be
incurred pursuant to the DBS surgery or replacement of the pulse generator.
The DBS surgery and replacement of the pulse generator must be undertaken in a government-
funded hospital.
For both the Deep Brain Stimulation surgery and replacement of the pulse generator, the
Parkinson’s Patients, Caregivers, family members of the Parkinson’s Patients, doctors and
supplier of the hardware must agree to allow ALL the following details to be published with
completely open transparency, in the Lloyd Tan Trust Fund website (www.lloydtan-trust.com) and
in all other forms of reports:
(i)
combined income of the Parkinson’s Patients, Caregivers and family members of the Parkinson’s Patients; the medical reports of the Independent Neurologist, Independent Neurosurgeon, and the Neurologist and Neurosurgeon who performed the DBS surgery, together with the MRI brain scans (both before and after surgery); invoices by supplier of the hardware and the amount of financial assistance paid by the Lloyd Tan Trust Fund; details of the government-funded hospital where the DBS surgery or replacement of the pulse generator was undertaken, together with the report of the medical director of the said hospital; photographs and/or video clips of the Parkinson’s Patients, that wil illustrate the benefits of the DBS surgery or replacement of the pulse generator; and (vii) any other forms of reports that are produced pursuant to the financial assistance and the DBS surgery or replacement of the pulse generator.
Breach

If there is any evidence that the said Parkinson’s Patient has breached any one of the conditions
and eligibility criteria stated above, the Trustee is at liberty to take any of the following actions
upon seeking legal advice:-
(i)
to institute legal proceedings against the said Parkinson’s Patient and/or doctors (Neurologist and Neurosurgeon who performed the Deep Brain Stimulation surgery) to recover the total sum of the financial assistance provided by the Lloyd Tan Trust Fund for the said Parkinson’s Patient; and/or to publish a complete report on the breach of agreement, including the identities of the Parkinson’s Patient and doctors (Neurologist and Neurosurgeon who performed the Deep Brain Stimulation surgery) in the Lloyd Tan Trust Fund website (www.lloydtan-trust.com) and in all other forms of reports; and/or to submit a complete report on the breach of agreement to the medical association (or council) of the country where the doctors (Neurologist and Neurosurgeon of the hospital where the Deep Brain Stimulation surgery is carried out) are practising. “Independent” means not having any of the following: (a) family relationship, such as father, or mother, or husband, or wife, or brother, or sister, or spouse of brother or sister, or uncles, or aunties, or cousins, or spouses or children of uncles or aunties or cousins; business relationship, such as owning shares in the business or company of the other, consultant or supplier or customer to the business or company of the other, and business relationship of family members specified in (a) above; professional relationship, such as working in the same institution or company. “Neurologist” means a medical doctor (whose basic medical degree is recognised by, and registered with the national medical council), who has undergone training specifically in the field of Neurology (brain diseases) at established neurology centres for a minimum period of three years, and who has subsequently undergone further training specifically in Movement Disorders (Parkinson’s Disease) at established movement disorder centres for a minimum period of six months. It is preferable, but not compulsory, that the Neurologist has directly been involved in the Deep Brain Stimulation surgery previously. "Significant Financial Constraint" refers to the financial condition of the Parkinson’s Patient, including immediate family members (spouse, brother, sister and child/children) and Caregivers (distant family members who are taking care of the Parkinson’s Patient instead of spouse or child/children), which is deemed by the Trustee to be reasonably insufficient to fund the Deep Brain Stimulation surgery for the Parkinson’s Patient, after taking into consideration of gross total income deducting reasonable living expenses of dependents. For this purpose, the annual income tax return and latest salary slips have to be submitted together with the application to the Working Committee appointed by the Trustee. Schedule II
Protocol for Deep Brain Stimulation (DBS) surgery in Parkinson’s Disease

Inclusion criteria

a)
This is determined by the levodopa challenge test1: The patient is assessed in the morning after overnight withdrawal of antiparkinsonian drugs (for at least 12 hours) and without long-acting dopamine agonists for three days. The UPDRS2 (optional) and dyskinesia scores3 (optional) are documented. After a suprathreshold dose of levodopa (at least 1.5 times the usual morning dose of levodopa), a second examination is carried out when patient reports to be in the best “on” condition. The UPDRS and dyskinesia scores (optional) are repeated. If the response is not satisfactory, the patient is given a higher dose of levodopa and then re-examined. Significantly severe and objective disability despite maximal medical therapy Significant disability (resulting in significant impairment of quality of life) despite maximal medical therapy should be present in order to justify the risk of surgery. Maximal medical therapy is arbitrarily defined as requiring at least a total of 1000 mgs of levodopa per day (in any available formulation, e.g. Madopar, Sinemet, Stalevo) plus at least three other medications of different classes for PD, each taken at maximum daily doses.
Exclusion criteria

a)
presence of severe vascular disease ; hypertension ischemic heart disease, clinical or Magnetic Resonance Imaging (MRI) evidence of severe cerebrovascular disease (stroke). presence of evolving cancer or any other life-threatening condition. Presence of dementia (based on Diagnostic and Statistical Manual of Mental Disorders, DSM-III criteria). Psychiatric complications; psychosis (except drug-induced), severe depression.
References

1.
Benabid AL, Krack P, Benazzouz A, Limousin P et al. Deep brain stimulation for the subthalamic nucleus: methodologic aspects and clinical criteria. Neurology 2000 ; 55 (12 Suppl 6) : S40-S44. Fahn S, Elton SL, UPDRS Development Committee. Unified Parkinson’s Disease Rating Scale. In : Fahn S, Marsden CD, Calne D, Goldstein S, eds. Recent developments in Parkinson’s Disease. Vol. 2. Florham Park, N.J : MacMillan Healthcare Information, 1987 : 153-63. Guy W. ECDEU assessment manual for psychopharmacology, revised. Department of Health, Education and Welfare, Publication No. (ADM) 76-338. Rockville, MD : National Institutes of Mental Health, 1976 : 534-7.

Source: http://www.parkinsoninfo.my/wp-content/uploads/2012/10/application_form.pdf

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