[FORM TO BE COMPLETED BY PATIENT OR PATIENT ORGANIZATION]

CASE REPORT on patient involvement in payer health care decisions to access new therapies: [INSERT TITLE OF CASE REPORT HERE (should, at minimum include names of patient or patient group therapeutic area and payer organization)]   

PROVIDED BY:
Add your company/organization name/email/telephone number here
	Benefits 
Add text here - Describe what you did that improved the HTA process and/or produced a result that helped your patient community (150 words max)	
PARTNER(S) INVOLVED: 
Add patient partner(s) (and potentially other partners) here, if this can be disclosed. Otherwise mention the type of organization/disease 
		
Level of involvement: Choose one of: Patient (1) Collaboration, e.g., working together with payer; (2) Consultation, e.g., asked for information or opinion; or (3) Minimal involvement 
Time commitment: Answer in months, weeks, days, hrs. 
Was sufficient time given? Answer yes, or no
		
Type of patient involvement: [Choose one or more of the following]
[ ] Study design to produce evidence
[ ] HTA topic selection 
[ ] Scoping 
[ ] Submission of evidence 
[ ] Presentation of patient experience to expert committee 
[ ] Sitting on an HTA decision-making committee 
[ ] Consultation on recommendations 
[ ] Patient friendly summaries 
[ ] Dissemination/communication 
[ ] Designing & reviewing patient engagement processes 
[ ] Use HTA to inform charity investments 
[ ] Contributing to governmental review of HTA 
	Challenges and negative outcomes Add text here – What problems did you encounter and how did you try and resolve them? How successful were you? Were there any issues you could not resolve? (150 words max)

Type of patient or organization involved, tick all that apply: 
[ ] Patients with personal disease experience 
[ ] Expert patient(s) / patient advocate(s) with good expertise on disease, but little payer experience
[ ] Expert patient(s) / patient advocate(s) with good expertise on disease and good payer experience 
[ ] Other, describe here: 
		
Type of payer: Choose 1 of:
[ ] Local institution, e.g., hospital
[ ] Regional/multiple institutions, e.g., municipality
[ ] private insurance
[ ] public insurance, e.g., national health insurance 
[ ] special program, e.g., rare disease or special access fund 
[ ] other
		
Description of the payer decision-making process: Add text here - Provide link to payer process if possible; describe how patients were involved’ what was the objective? when did this happen?, max 200 words
	Discussion and learning 
Add text here – What would you do differently next time? What should others do differently to help you be better involved in the HTA process? (150 words max)