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Welcome to Our Parkinson's Place


I copy news articles pertaining to research, news and information for Parkinson's disease, Dementia, the Brain, Depression and Parkinson's with Dystonia. I also post about Fundraising for Parkinson's disease and events. I try to be up-to-date as possible. I have Parkinson's
diseases as well and thought it would be nice to have a place where
updated news is in one place. That is why I began this blog.
I am not responsible for it's contents, I am just a copier of information searched on the computer. Please understand the copies are just that, copies and at times, I am unable to enlarge the wording or keep it uniformed as I wish. This is for you to read and to always keep an open mind.
Please discuss this with your doctor, should you have any questions, or concerns. Never do anything without talking to your doctor. I do not make any money from this website. I volunteer my time to help all of us to be informed. Please No advertisers, and No Information about Herbal treatments. This is a free site for all.
Thank you.


Saturday, August 30, 2014

Study Shows Pesticide Exposure Dramatically Increases Risk of Developing Parkinson’s Disease

New research published in the journal Neurology further supports the causative link betweenpesticide exposure and Parkinson’s disease. Emanuel Cereda, M.D., Ph.D., of the IRCCS University Hospital San Matteo Foundation in Pavia, Italy, and coauthor Gianni Pezzoli, M.D., analyzed 104 studies published between 1975 and 2011 to determine the link between pesticides and solvents to Parkinson’s disease.
The researchers analyzed exposure using information on proximity to large farms likely to use pesticides, likelihood of well water consumption and occupations that cause greater exposure to pesticides and solvents used to kill weeds, insects, fungus and rodents. Overall, researchers found exposure to pesticides increased the risk of developing the disease by 33 percent to 80 percent. Some pesticides were considered to be of higher risk than others, with weed killers likeparaquat and fungicides maneb and mancozeb causing twice the risk for development of Parkinson’s disease. While risk increased the longer people were exposed to pesticides, researchers indicate there is still a need for further research on the chemical threshold for harm to the brain.

Photo courtesy of Shutterstock

The study builds on recent research that has linked Parkinson’s disease to pesticide exposure. In a 2011 article published in the journal Molecular Neurodegeneration, researchers at the University of Missouri School of Medicine invented a new antibody that allowed them to detect how oxidative stress affected proteins when exposed to a variety of environmental toxins, such as the pesticide rotenone. In another study, individuals with certain genetic factors who are exposed to organophosphates exhibited more than twice the risk of Parkinson’s disease compared to others without exposure. Another recent publication found that rural residents who drank contaminated well water had an increased risk—up to 90 percent—of developing Parkinson’s.
The research adds to the body of knowledge on the role of pesticide exposure in diseases like Parkinson’s. “I think the study is actually a big advance in our research knowledge of the relation between chemical exposures and the basic neurological injuries,” said Arch Carson, Ph.D., at the University of Texas School of Public Health in Houston, TX. “This report is the first to show that there is a positive relationship between not only insecticides and herbicides but also some other solvent chemicals to which many people are exposed and the development of Parkinson’s syndrome.”
The second most common neurodegenerative disease, Parkinson’s disease occurs when nerve cells in the substantia nigra region of the brain are damaged or destroyed and can no longer produce dopamine, a nerve-signaling molecule that helps control muscle movement. People with Parkinson’s have a variety of symptoms including loss of muscle control, trembling and lack of coordination. They may also experience anxiety, constipation, dementia, depression, urinary difficulties and sleep disturbances. Over time, symptoms intensify. At least 1 million Americans have Parkinson’s and about 50,000 new cases are diagnosed each year. With less than one percent of cases caused by genetics, researchers have been looking for the potential risk factors for developing Parkinson’s disease.

Friday, August 29, 2014

Kinecting” to telemedicine


26 August 2014 | Gustaf von Dewall, Business Developer
A solution from the videogame world—Kinect for Windows—could become a revolutionary new way for patients with Parkinson's disease to do rehab at home, and for physicians to remotely monitor how a person’s medication works. It also shows that telemedicine does not have to be expensive.
Do we really need special devices and highly advanced and expensive technology for telemedicine? Maybe in some cases, but as consumer technology evolves and gains more advanced functionality, it will be more than sufficient for many cases of telemedicine.
​One example of consumer technology that is more than suitable to use in telemedicine is Kinect. Out of the box, it comes with functionality such as depth sensing, HD video, and skeleton tracking.
We at Softronic in collaboration with Karolinska University Hospital, are conducting a project called Kinecting Parkinson's to demonstrate the ability of a more cost-efficient way to do follow-up. The goal is to make this available for a larger number of patients with Parkinson's disease.
We have verified the technical platform, and the software supports five movements based on the standardized scale Unified Parkinson’s Disease Rating Scale (UPDRS). Examples of the movements are
  • Finger taps where the patient taps the thumb with the index finger in rapid succession
  • Leg Agility where the patient taps heel on the ground in rapid succession picking up entire leg
  • Rapid Alternating Movements of Hands - Pronation-supination movements of hands, vertically and horizontally, with as large an amplitude as possible, both hands simultaneously
The purpose of the movements is to evaluate the motoric functions of the patients. Data from the movements are analyzed and presented in an interface that the doctor can use to make an assessment of the patient. Softronic and Karolinska have started patient trials.
​The use of Kinect for telemedicine received a lot of interest from the doctors attending the Neurology and Care at a Distance conference, which gathered some of the world’s leading neurologists. The combination of a much lower price than standard telemedicine equipment with the possibility of remote assessment and remote visits seems to be a winning combination—at least according to the comments of the doctors. Also the fact that the doctor can choose to assess the exercises live or examine the graphs and a video of the exercises at a later time was seen as big advantage.
This also enables more efficient follow ups. Today patients with Parkinson's disease see their doctor once or twice a year. Giving the doctor the possibility of remote assessment, the doctor can also do follow-ups of patients on the basis of when needed instead routinely once or twice a year. Thus, the doctor will be able to focus on the patients that need follow ups. By using the Kinect the doctor will also have the possibility to do the follow up remotely and only the patients that really need to will have to visit the doctor at the hospital.
Another advantage of using Kinect is that it is a device that you can find in many households. As a patient, the device would not prompt a lot of questions because it does not “signal” that you are suffering from a disease.
In the future we see additional functionality being added. We are now in the process of looking into gamification and using this both as a way to make rehabilitation more fun and to involve the patients’ relatives in the rehabilitation. Imagine a situation where grandchildren playing a game with their grandfather would help with rehabilitation.
The solution can also be used to educate neurologists specializing in Parkinson’s disease and for second opinions. This will be possible since we record and save the movements. When a second opinion is needed it the exercises will be available for assessment. Either the patient or the treating doctor can initiate the initiative for a second opinion.
We also hope to be able to crowd-source the data collected from the exercises, allowing patients to upload their data to patient communities or to personal health records such as Microsoft HealthVault.
Have a comment or opinion on this post or a question for the author? Please send us an email or let us know on Facebook or via Twitter.​​​​​​​​​​​​​​​​
Gustaf von Dewall

Speech Therapy for Parkinson's Disease


Dysarthria (difficulty speaking) and dysphagia (difficulty swallowing) can be severely limiting symptoms of Parkinson’s disease and can be helped by referral to a speech therapist. Until recently, traditional speech therapy had not provided sustained improvement. A new program called the Lee Silverman Voice Therapy Program has been developed, which has demonstrated significant value for patients with Parkinson’s disease. The patient should be referred to a speech therapist experienced in administering the Lee Silverman Voice Therapy Program.
Information tips for improving communication

As the muscles weaken in the voice box (larynx), throat (pharynx), roof of the mouth (soft palate) tongue, and lips, people with Parkinson’s disease might find it difficult to pronounce words clearly.
Some resulting speech impairments might be:
            Hoarse or strained voice
            Muffled or nasal-sounding voice
            Unclear or slurred speech
Speech-language therapists can help people with Parkinson’s disease maintain as many communication skills as possible. They also teach techniques that conserve energy, including non-verbal communication skills. Speech-language therapists are also available to:
            Recommend appropriate communication techniques to provide treatment that will aid in the success of daily activities.
            Treat all types of speech, language, and communication problems.
            Evaluate swallowing function and recommend changes as necessary.

Tips to maintain and enhance communication
.    Choose an environment with reduced noise. It can be quite tiring to try to "talk over" the television or radio.
.    Speak slowly.
.    Be certain your listener can see your face. Look at the person while you are talking. A well-lit room enhances face-to-face conversation, increasing intelligibility.
.    Use short phrases. Say one or two words, or syllables per breath.
.    Over-articulate your speech by prolonging the vowels and exaggerating the consonants.
.    Choose a comfortable posture and position that provide support during long and stressful conversations.
.    Be aware that exercises intended to strengthen weakening muscles might be counter-productive. Always ask your speech-language therapist which exercises are right for you.
.    Plan periods of vocal rest before planned conversations or phone calls. Know that fatigue significantly affects your speaking ability. Techniques that work in the morning might not work later in the day.
.    If you are soft spoken and your voice has become low, consider using an amplifier.
.    If you are on a respirator (with fully inflated cuffs), an electrolarynx or respiratory tube that provides an alternative air source might be used.
.    If some people have difficulty understanding you, the following strategies might help:
                        If you are able to write without difficulty, always carry a paper and pen as a backup so you can write down what you are trying to say.
                        If writing is difficult, use an alphabet board to point or scan to the first letter of the words that are spoken.
                        Spell words out loud or on an alphabet board if they are not understood.
                        Establish the topic before speaking.
                        Use telegraphic speech. Leave out unnecessary words to communicate the meaning of the topic.

Non-verbal communication

            Non-verbal communication, also called augmentative and alternative communication (AAC), is a method of communicating without spoken words. When communication needs cannot be met through speech, the following techniques can be practiced by people with Parkinson’s disease:
            Residual speech (making the best use out of what speaking ability is left)
            Effective use of expressions and gestures
            Non-verbal communication can help people with speech difficulties actually speak better by:
            Reducing the frustration and stress of being unable to communicate
            Alleviating the pressure to speak
            Allowing the person to be more relaxed and come across in a more intelligible manner

Assistive devices
Here’s a sample of the assistive devices that are available to help people with Parkinson’s disease communicate more clearly.
Palatal lift
This is a dental apparatus that is similar to a retainer. It lifts the soft palate and stops air from escaping out of the nose during speech.
Amplification
This is a personal amplifier that can be used to increase vocal loudness in soft-spoken people. The amplifier also decreases voice fatigue.
TTY telephone relay system
This is a telephone equipped with a keyboard so speech can be typed and read by a relay operator to the listener. Either the whole message can be typed or just the words that are not understood can be typed.
Low-technology devices
Notebooks and language boards can be used as alternative communication techniques.
High-technology electronic speech enhancers, communication devices
Computers with voice synthesizers and dedicated communication devices are available.
Patients who are interested in purchasing electronic communication aids should discuss this with a speech-language therapist before contacting sales representatives for these devices.

HELPFUL PARKINSON’S RESEARCH FROM PHYSICS AND ASTRONOMY?


laser protein


Lisa Lapidus, Ph.D., who is an associate professor of physics and astronomy, was fascinated by the idea that eating spicy food could slow the development of PARKINSON’S DISEASE.  So she undertook studies of the spice, curcumin, which is thought to be the major substance in tumeric often used in South East Asian curries and cooking.  It has a reputation for being anti-inflammatory and helpful for osteoarthritis. Unfortunately, she found that the molecule of curcumin, while helpful in other diseases, was too large to pass across the blood brain barrier.A non-traditional physics lab at Michigan State University has been working to advance medical solutions by combining physics and biochemistry.  And it is working.
In doing that research, she learned about protein aggregations and studied the rate at which proteins mis-fold.  Using lasers, she was able to study the rate at which proteins formed aggregates.  She found that if the proteins fold either faster or slower than the rate at which they bump into each other, then aggregation is slow.  However, if they are bumping into each other at the same rate as when they are reconfiguring, then they will swiftly clump together causing aggregation and neurodegeneration follows.
When a person with PARKINSON’S presents with the symptoms, the process of protein aggregation has already begun.  However, there is a patented molecule, called CLR01, which mimics the action of curcumin to prevent protein aggregates from forming.  And CLR01 is a small enough molecule that it can cross the blood brain barrier.  This small CLR01 molecule can be sent to its target site and will speed up the reconfiguration of the proteins and actually stop the early stages of them forming aggregates.  This molecule attaches to the amino acid lysine, which is part of the protein, and acts like a claw or a pair of molecular tweezers to prevent binding with other proteins.
This CLR01 molecule used in this way to prevent aggregations of proteins from forming in the brain is an excellent candidate for a new drug that can be used to stop PARKINSON’S DISEASE early in the game and keep it from becoming the disabling disease. Hopefully, this research will move to the clinical trial stages soon and become a valuable resource for treating not only PARKINSON’S DISEASE, but other neurodegenerative diseases too.
S. Achaya, B.M. Safaie, P Wonkonkathep, M.I. Ivanova, A. Attar,  F.G. Klamer, T. Schrader, .J.S. Loo, G. Bitan, L.J. Lapidus.  Molecular Basis for Preventing Synuclein Aggregation by a Molecular Tweezer; Journal of Biological Chemistry, 2014, 289 (15); 10727 DOI 10.1074/jbc.M113.524520


The striatum acts as hub for multi sensory integration


The striatum acts as hub for multisensory integration
A new study from Karolinska Institutet in Sweden provides insight on how the brain processes external input such as touch, vision or sound from different sources and sides of the body, in order to select and generate adequate movements. The findings, which are presented in the journal Neuron, show that the striatum acts as a sensory 'hub' integrating various types of sensory information, with specialised functional roles for the different neuron types.


The striatum is the main input structure in the basal ganglia, and is typically associated with motor function", says Principal Investigator Gilad Silberberg at the Department of Neuroscience. "Our study focuses on its role in processing sensory input. This is important knowledge, since the striatum is implicated in numerous diseases and disorders, including Parkinson's disease, Huntington's disease, ADHD and Tourette syndrome."
The striatum is the largest structure in a collection of brain nuclei called the basal ganglia, which are located at the base of the forebrain. It is involved in motor learning, planning and execution as well as selecting our actions out of all possible choices, based on the expected reward by the dopamine system. Most research performed in the striatum is focused on the motor aspects of its function, largely due to the devastating motor symptoms of the related diseases.
However, in order to select the correct actions, and generate proper motor activity it is essential to continuously process sensory information, often arriving from different sources, different sides of the body and from different sensory modalities, such as tactile (touch), visual, auditory, and olfactory. This integration of sensory information is in fact a fundamental function of our nervous system.
In the current study, researchers Gilad Silberberg and Ramon Reig show that individual striatal neurons integrate sensory input from both sides of the body, and that a subpopulation of these neurons process sensory input from different modalities; touch, light and vision. The team used intracellular patch-clamp recordings from single neurons in the mouse striatum to show their responses to whisker stimulation from both sides as well as responses to visual stimulation. Neurons responding to both visual and tactile stimuli were located in a specific medial region of the striatum.
"We also showed that neurons of different types integrate sensory inputs in a different manner, suggesting that they have specific roles in the processing of such sensory information in the striatal network", says Gilad Silberberg.
The work was funded by an ERC starting grant to Gilad Silberberg, and grants from the Knut and Alice Wallenberg Foundation, the Karolinska Institutet Strategic Research program in Neuroscience (StratNeuro), and the Swedish Research Council.

http://en.wikipedia.org/wiki/Karolinska_InstituteGilad Silberberg & Ramon Reig, Karolinska Institutet

Wednesday, August 27, 2014

Dealing with Parkinson's Disease and medical debt

Parkinson’s disease manifests differently in each person. For some, life goes on with modest disruption. For others, essential tasks that may include working, are not possible. The financial impact of Parkinson’s may include loss of income, difficulty paying for medical expenses like medications and therapies, or worry about paying for long term care.
If a Parkinson’s disease diagnosis has made employment impossible, or if medical expenses have gotten out of control making it impossible to keep up, there are options that can help reduce debt, or in extreme cases, eliminate it all together.
As you consider the possibility of seeking financial help, it’s vital that you not blame yourself for circumstances that are out of your control.  Illness, is after all, not your fault. If you are finding this difficult to accept, consider the following information from CNN:
"Bankruptcies due to medical bills increased by nearly 50 percent in a six-year period, from 46 percent in 2001 to 62 percent in 2007, and most of those who filed for bankruptcy were middle-class, well-educated homeowners, according to a report that will be published in the August issue of The American Journal of Medicine".
A life time of being financially prudent, with health insurance, does not prevent the possibility that health care bills resulting from treatment for Parkinson’s can be ruinous. Many people find in the later stages of the disease that they need more physical or occupational therapy than what their insurance covers; some medications may not be covered by every insurance company’s formulary, which can quickly add up.
"Unless you're a Warren Buffett or Bill Gates, you're one illness away from financial ruin in this country," says lead author Steffie Woolhandler, M.D., of the Harvard Medical School, in Cambridge, Mass. "If an illness is long enough and expensive enough, private insurance offers very little protection against medical bankruptcy, and that's the major finding in our study."
Hopefully, you are not at the point of declaring bankruptcy, but if you are, remember that bankruptcy laws were enacted to give those with impossible financial obligations a chance to start over. There is no shame in doing what millions of Americans, and countless businesses, have done to relieve financial pressure and begin again with a clean slate.
There are different types of bankruptcies and conditions that apply to all of them. In every case, certain income, and savings, and property types are exempted, or have some exemptions. Be certain to consult an attorney with experience in bankruptcy law. Most bankruptcy lawyers offer a free initial consultation, and many offer payment terms.
If medical obligations resulting from Parkinson’s disease treatments have not pushed you to the point of declaring a bankruptcy, there are ways to reduce existing, and planned medical expenses.
 Negotiation
Negotiating service fees from your primary care physician, neurologist, hospital, or other health care provider, may seem unseemly – and something you would prefer to avoid. It’s natural to feel this way, but understand that your doctor is also in business – and that means dealing with payment issues with his or her customers.
Health care providers are also consumers, and they know the financial drain medical expenses can have. They are used to negotiating with patients as well as health insurance companies. Giving discounts for unusual circumstances is common practice, and significant discounts are not unusual. Providers will also likely be able to provide resources that can help with the cost of medications.
When you begin a negotiation – whether before a service has been received or after - the key to being successful is knowing the range of possible outcomes. For example, you may discover you have been charged $10,000 for a certain procedure or group of procedures. Unable to pay the bill, you ask the doctor or hospital for a reduction down to $3000. The business/billing office refuses your offer. Had you done the necessary research, you would have known that bottom end of the range of expected payment for that procedure in your geographic are  is $4000, an offer that likely would have met their criteria and been accepted.
Information is key for medical negotiations. Fox Business tells us that “… patients need to know the fair market price for a procedure or treatment before making any decisions so they can plan accordingly. Information about the cost for different treatments based on the region or even city is readily available online. Consumers can also find the rate the government pays for medical procedures online…” That rate can often be 25% less than even what insurance companies pay.
Know the real costs of hospital and doctor visits and procedures
Knowing the costs of a procedure or series of treatments is a major component of a successful negotiating strategy. You can find information on medical services and procedures by looking at your insurance company’s website; in most cases, they publish their negotiated rates.
If you are having difficulty, New Choice Health is one of several websites that can help you find these figures. With a modest effort you will be successful in determining how much doctors and local hospitals charge and the size discount normally given to an insurer. You will also be able to see a listing of a ‘fair’ self-pay price, which is normally considered a small amount above the fee normally received from an insurer.
How to negotiate before treatment
For procedures that are done on a non-emergency basis, prepare for your negotiation by determining price reference points charged for the procedure or service.  Before you schedule the procedure, visit the doctor’s office, or hospital, and ask to speak with the business office, or patient business representative.
Explain to the representative that the estimate for the Parkinson’s treatments are high, and would they please make a reduction? This is an effective strategy for those in a competitive market, with many doctors and hospitals capable of providing the treatment. In an area where this is not the case, another approach, along the lines of:  ‘I simply cannot afford to pay this amount. Can you please make a reduction”, would be a good strategy.
There are endless variations of negotiation strategies, and the key is to use one you are comfortable with. If you simply cannot do it, then bring a family member who can. It’s best to take a non-emotional approach, keeping the conversation and negation focused on the payment options.
How to negotiate after treatment
If the procedure or services have been completed by the doctor or hospital, the negation process is similar, but with subtle and important differences. The first of these is the absence of choice. The part of your negotiating strategy that included the option to go elsewhere is no longer needed. The other difference is the simple fact that what is done – is done. The doctor or hospital no longer view you and the services needed as representing a financial opportunity which they would like to get the as much out of as is ethically reasonable.
Now, you represent a debt that they want to recover, and they will do whatever is possible to get the most they can from that debt. In most cases, doctors and hospitals have extended payment plans, sometimes with interest and sometimes without. While a full payment of the settled amount can be an important negotiation tool, if that is not possible a payment plan for the settled amount is a common request, and normally granted.
Healthcare providers, as mentioned, are understanding of the predicament many of their patients find themselves in and are willing to discuss and negotiate bills. But, bear in mind, this goodwill is usually limited to one negotiation. Failure to meet the agreement frequently will likely result in quick collection action.
It’s also the case that both hospitals and doctors do not want to attempt legal remedies to collect a debt. Collection services take as much as 50% of the collected amount, plus any costs incurred in the collection. On an average basis, the total received from all collected accounts may be in range of 25%, and the health care provider may wait a considerable period of time to be paid from the collection agency. If you make an offer of 35%, there is a good chance it will be accepted, and a better chance if you can offer immediate payment.
If an offer has been agreed to, and for one reason or another payment is not made, be certain to have the agreement put in writing. This may seem obvious, but with healthcare providers, we tend to forget the need to secure basic protections.
“Get explanations in writing and take protests to the top. All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections.” - Los Angeles Times


Dealing with collection agencies
If your account has been sent to a third party collection agencies, there are plenty of options still available.
Credit.com tells us:
“How you ultimately resolve a debt with a contingency debt collector is going to depend on: your monthly cash flow that can be used to make payments; the parameters the collector has to work with on their end; and even by the date on the calendar.”
Credit.com goes on to say:
“Setting up a payment arrangement you can afford given your monthly budget is not all that difficult. And if the collector can get you set up with a payment, they often get to retain the account while your payments are being made. This means your interests and the collector’s are aligned when you are actively looking for a solution.”

Be realistic in your plan. It is easy under the pressure of negotiating to agree to a price that may reflect a big discount, but is still outside your means. Be completely honest about what you can pay, and how long you will need to pay it.
Payment as a negotiating tool
Most experts advise against using credit cards for payment.  CBS News tells us:
 “Forgo the credit card if you think you might be asking for a discount later. Using plastic puts you in a weaker bargaining position with the hospital. ‘We recommend against credit cards, because the hospital loses any interest in negotiating with you’ once they have your money, says Carol Pryor, policy director at The Access Project. And your bills could be even higher if you end up paying interest on the charges.”
If the procedure has been done, using a credit card is a valid option.
Getting help
Some of us simply are not comfortable negotiating anything, let alone a hospital bill or a bill to a doctor that we have come to depend upon and trust. This does not change the need for relief, but it does change the strategy. There are services like Medical Billing Advocates of America, who will negotiate on your behalf for a fee. There are nonprofit advocates as well, and an attorney is usually an excellent choice.
The Federal Trade Commission (FTC) says that:
Reputable credit counseling organizations can advise you on managing your money and debts, help you develop a budget, and offer free educational materials and workshops. Their counselors are certified and trained in consumer credit, money and debt management, and budgeting. They discuss your entire financial situation with you, and help you develop a personalized plan to deal with your money problems. An initial counseling session typically lasts an hour, with an offer of follow-up sessions
The los Angeles Times provides this advice:
Seek help and file complaints. If your bill is large or you're having a hard time making headway, patient advocates can help sort things out. For either a flat fee or a share of the money you save, organizations such as Medical Billing Advocates of America (www.billadvocates.com) and Health Proponent (www.healthproponent.com) can help you fight charges or lower your bill.
If you're being stonewalled by your healthcare provider, and your insurer hasn't helped, Quincy of Consumers Union suggests filing a complaint with your state's department of insurance. In California, patients with HMO coverage can file a complaint with the California Department of Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov. Californians with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or visit http://www.insurance.ca.gov. If your provider isn't contracted with your insurer, your state's attorney general's office is a place to turn for help.

Government Resources that help with medical bills:

If you are receiving Medicare and need assistance. contact the Centers for Medicare and Medicaid Services (CMS) or view Programs to Help You Pay Medical Expenses. You can also call or write to CMS
Phone: 1-877-267-2323 or 1-410-786-3000
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore MD 21244-1850