Life Care Plan Cost Summary Worksheet
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LIFE CARE PLAN COST SUMMARY WORKSHEET
Case Name: [________________________________]
Case/Claim Number: [________________________________]
Date of Injury: [__/__/____]
Date Prepared: [__/__/____]
Prepared By: [________________________________]
SECTION 1: CLAIMANT INFORMATION
Name: [________________________________]
Date of Birth: [__/__/____]
Age at Injury: [____]
Current Age: [____]
Gender: [________________________________]
Life Expectancy:
| Parameter | Value |
|---|---|
| Normal Life Expectancy (from actuarial tables) | [____] years |
| Reduced Life Expectancy (if applicable) | [____] years |
| Life Expectancy Used for Calculations | [____] years |
| Expected Age at End of Life Care Period | [____] years |
| Remaining Years for Cost Projection | [____] years |
SECTION 2: INJURY SUMMARY
Primary Diagnosis:
[________________________________]
ICD-10 Code: [________]
Functional Impairments:
☐ Complete paralysis (quadriplegia/tetraplegia)
☐ Incomplete paralysis (paraplegia)
☐ Traumatic brain injury (TBI)
☐ Spinal cord injury
☐ Amputation(s): [________________________________]
☐ Chronic pain syndrome
☐ Cognitive impairment
☐ Visual impairment
☐ Hearing impairment
☐ Other: [________________________________]
Current Level of Care:
☐ Independent with modifications
☐ Requires minimal assistance
☐ Requires moderate assistance
☐ Requires extensive assistance
☐ Total care dependent
SECTION 3: LIFE CARE PLANNER INFORMATION
Life Care Planner Name: [________________________________]
Credentials: [________________________________]
Organization: [________________________________]
Date of Evaluation: [__/__/____]
Date of Report: [__/__/____]
Report Attached: ☐ Yes ☐ No
SECTION 4: PROJECTED EVALUATIONS
Medical Evaluations
| Evaluation Type | Frequency | Years | Cost/Visit | Annual Cost | Lifetime Cost |
|---|---|---|---|---|---|
| Physiatry/Rehab Medicine | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Neurology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Orthopedics | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Urology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Pulmonology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Cardiology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Gastroenterology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Ophthalmology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Dermatology | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Primary Care | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Other: [________________] | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| SUBTOTAL - Medical Evaluations | $ [________] | $ [________] |
Psychological/Neuropsychological Evaluations
| Evaluation Type | Frequency | Years | Cost/Visit | Annual Cost | Lifetime Cost |
|---|---|---|---|---|---|
| Psychological Evaluation | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Neuropsychological Testing | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Psychiatric Evaluation | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| SUBTOTAL - Psych Evaluations | $ [________] | $ [________] |
SECTION 5: PROJECTED THERAPEUTIC MODALITIES
| Therapy Type | Frequency | Duration | Cost/Session | Annual Cost | Lifetime Cost |
|---|---|---|---|---|---|
| Physical Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Occupational Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Speech/Language Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Cognitive Rehabilitation | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Recreational Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Aquatic Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Vocational Rehabilitation | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Individual Psychotherapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Group Therapy | [____]/wk | [____] yrs | $ [________] | $ [________] | $ [________] |
| Family Counseling | [____]/mo | [____] yrs | $ [________] | $ [________] | $ [________] |
| Pain Management Program | [____]/yr | [____] yrs | $ [________] | $ [________] | $ [________] |
| Other: [________________] | [____] | [____] yrs | $ [________] | $ [________] | $ [________] |
| SUBTOTAL - Therapeutic Modalities | $ [________] | $ [________] |
SECTION 6: DIAGNOSTIC TESTING
| Test Type | Frequency | Years | Cost/Test | Annual Cost | Lifetime Cost |
|---|---|---|---|---|---|
| MRI | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| CT Scan | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| X-Rays | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Ultrasound | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| EMG/Nerve Conduction | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| EEG | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Urodynamic Studies | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Pulmonary Function Tests | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Lab Work/Blood Tests | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| Other: [________________] | [____]/yr | [____] | $ [________] | $ [________] | $ [________] |
| SUBTOTAL - Diagnostic Testing | $ [________] | $ [________] |
SECTION 7: WHEELCHAIR/MOBILITY NEEDS
| Item | Initial Cost | Replacement Interval | Lifetime Qty | Lifetime Cost |
|---|---|---|---|---|
| Power Wheelchair | $ [________] | [____] yrs | [____] | $ [________] |
| Manual Wheelchair (backup) | $ [________] | [____] yrs | [____] | $ [________] |
| Shower/Commode Chair | $ [________] | [____] yrs | [____] | $ [________] |
| Standing Frame | $ [________] | [____] yrs | [____] | $ [________] |
| Walker | $ [________] | [____] yrs | [____] | $ [________] |
| Cane/Crutches | $ [________] | [____] yrs | [____] | $ [________] |
| Wheelchair Cushion | $ [________] | [____] yrs | [____] | $ [________] |
| Wheelchair Batteries | $ [________]/yr | annual | [____] yrs | $ [________] |
| Wheelchair Maintenance | $ [________]/yr | annual | [____] yrs | $ [________] |
| Other: [________________] | $ [________] | [____] yrs | [____] | $ [________] |
| SUBTOTAL - Wheelchair/Mobility | $ [________] |
SECTION 8: ORTHOTICS/PROSTHETICS
| Item | Initial Cost | Replacement Interval | Lifetime Qty | Lifetime Cost |
|---|---|---|---|---|
| Lower Extremity Orthosis (KAFO/AFO) | $ [________] | [____] yrs | [____] | $ [________] |
| Upper Extremity Orthosis | $ [________] | [____] yrs | [____] | $ [________] |
| Spinal Orthosis | $ [________] | [____] yrs | [____] | $ [________] |
| Prosthetic Limb | $ [________] | [____] yrs | [____] | $ [________] |
| Prosthetic Liners/Sleeves | $ [________]/yr | annual | [____] yrs | $ [________] |
| Other: [________________] | $ [________] | [____] yrs | [____] | $ [________] |
| SUBTOTAL - Orthotics/Prosthetics | $ [________] |
SECTION 9: AIDS FOR INDEPENDENT FUNCTION
| Category/Item | Cost | Replacement | Lifetime Cost |
|---|---|---|---|
| Bathroom Equipment | |||
| Transfer bench/tub seat | $ [________] | [____] yrs | $ [________] |
| Raised toilet seat | $ [________] | [____] yrs | $ [________] |
| Grab bars | $ [________] | one-time | $ [________] |
| Handheld shower | $ [________] | [____] yrs | $ [________] |
| Bedroom Equipment | |||
| Hospital bed | $ [________] | [____] yrs | $ [________] |
| Specialty mattress | $ [________] | [____] yrs | $ [________] |
| Patient lift/Hoyer | $ [________] | [____] yrs | $ [________] |
| Bed rails | $ [________] | [____] yrs | $ [________] |
| Communication Aids | |||
| Augmentative communication device | $ [________] | [____] yrs | $ [________] |
| Voice amplifier | $ [________] | [____] yrs | $ [________] |
| Other ADL Equipment | |||
| Adaptive utensils/equipment | $ [________] | [____] yrs | $ [________] |
| Reaching aids | $ [________] | [____] yrs | $ [________] |
| Other: [________________] | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Aids for Independent Function | $ [________] |
SECTION 10: DRUG/SUPPLY NEEDS
Medications
| Medication | Dosage | Monthly Cost | Annual Cost | Duration | Lifetime Cost |
|---|---|---|---|---|---|
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| [________________________________] | [________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Medications | $ [________] | $ [________] | $ [________] |
Medical Supplies
| Supply | Monthly Cost | Annual Cost | Duration | Lifetime Cost |
|---|---|---|---|---|
| Catheter supplies | $ [________] | $ [________] | [____] yrs | $ [________] |
| Bowel program supplies | $ [________] | $ [________] | [____] yrs | $ [________] |
| Skin care/wound supplies | $ [________] | $ [________] | [____] yrs | $ [________] |
| Incontinence supplies | $ [________] | $ [________] | [____] yrs | $ [________] |
| Respiratory supplies | $ [________] | $ [________] | [____] yrs | $ [________] |
| Nutritional supplements | $ [________] | $ [________] | [____] yrs | $ [________] |
| Other: [________________] | $ [________] | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Medical Supplies | $ [________] | $ [________] | $ [________] |
SECTION 11: HOME/FACILITY CARE
Attendant Care/Home Health
| Care Type | Hours/Day | Days/Week | Hourly Rate | Annual Cost | Duration | Lifetime Cost |
|---|---|---|---|---|---|---|
| Skilled Nursing (RN) | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| LPN/LVN | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| Home Health Aide | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| Personal Care Attendant | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| Companion/Supervision | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| Respite Care | [____] | [____] | $ [________] | $ [________] | [____] yrs | $ [________] |
| Case Manager | [____] hrs/mo | $ [________] | $ [________] | [____] yrs | $ [________] | |
| SUBTOTAL - Attendant Care | $ [________] | $ [________] |
Facility Care (if applicable)
| Facility Type | Rate | Duration | Total Cost |
|---|---|---|---|
| Skilled Nursing Facility | $ [________]/day | [____] days | $ [________] |
| Assisted Living Facility | $ [________]/mo | [____] mos | $ [________] |
| Residential Care Facility | $ [________]/mo | [____] mos | $ [________] |
| SUBTOTAL - Facility Care | $ [________] |
SECTION 12: HOME/VEHICLE MODIFICATIONS
Home Modifications
| Modification | Cost | Notes |
|---|---|---|
| Wheelchair ramp | $ [________________] | |
| Widened doorways | $ [________________] | |
| Accessible bathroom | $ [________________] | |
| Roll-in shower | $ [________________] | |
| Lowered counters/cabinets | $ [________________] | |
| Stair lift/elevator | $ [________________] | |
| Accessible flooring | $ [________________] | |
| Emergency response system | $ [________]/yr × [____] yrs | $ [________________] |
| Other: [________________________________] | $ [________________] | |
| SUBTOTAL - Home Modifications | $ [________________] |
Vehicle Modifications
| Modification | Cost | Replacement | Lifetime Cost |
|---|---|---|---|
| Wheelchair accessible van | $ [________] | [____] yrs | $ [________] |
| Van modifications (lift, etc.) | $ [________] | [____] yrs | $ [________] |
| Hand controls | $ [________] | [____] yrs | $ [________] |
| Wheelchair tie-downs | $ [________] | [____] yrs | $ [________] |
| Other: [________________] | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Vehicle Modifications | $ [________] |
SECTION 13: FUTURE SURGICAL/MEDICAL PROCEDURES
| Procedure | Anticipated Year | Probability | Est. Cost | Adjusted Cost |
|---|---|---|---|---|
| [________________________________] | [____] | [____]% | $ [________] | $ [________] |
| [________________________________] | [____] | [____]% | $ [________] | $ [________] |
| [________________________________] | [____] | [____]% | $ [________] | $ [________] |
| [________________________________] | [____] | [____]% | $ [________] | $ [________] |
| [________________________________] | [____] | [____]% | $ [________] | $ [________] |
| SUBTOTAL - Future Procedures | $ [________] |
SECTION 14: TRANSPORTATION
| Item | Annual Cost | Duration | Lifetime Cost |
|---|---|---|---|
| Medical transportation | $ [________] | [____] yrs | $ [________] |
| Accessible transportation services | $ [________] | [____] yrs | $ [________] |
| Vehicle operating costs (excess) | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Transportation | $ [________] | $ [________] |
SECTION 15: VOCATIONAL/EDUCATIONAL
| Item | Cost | Duration | Total Cost |
|---|---|---|---|
| Vocational evaluation | $ [________] | one-time | $ [________] |
| Job placement services | $ [________] | [____] mos | $ [________] |
| Retraining/education | $ [________] | [____] yrs | $ [________] |
| Assistive technology for work | $ [________] | [____] yrs | $ [________] |
| SUBTOTAL - Vocational/Educational | $ [________] |
SECTION 16: LIFE CARE PLAN COST SUMMARY
Cost Summary by Category (Nominal Dollars)
| Category | Annual Cost | Lifetime Cost |
|---|---|---|
| Medical Evaluations | $ [________________] | $ [________________] |
| Psychological Evaluations | $ [________________] | $ [________________] |
| Therapeutic Modalities | $ [________________] | $ [________________] |
| Diagnostic Testing | $ [________________] | $ [________________] |
| Wheelchair/Mobility | $ [________________] | $ [________________] |
| Orthotics/Prosthetics | $ [________________] | $ [________________] |
| Aids for Independent Function | $ [________________] | $ [________________] |
| Medications | $ [________________] | $ [________________] |
| Medical Supplies | $ [________________] | $ [________________] |
| Attendant/Home Health Care | $ [________________] | $ [________________] |
| Facility Care | $ [________________] | $ [________________] |
| Home Modifications | $ [________________] | $ [________________] |
| Vehicle Modifications | $ [________________] | $ [________________] |
| Future Procedures | $ [________________] | $ [________________] |
| Transportation | $ [________________] | $ [________________] |
| Vocational/Educational | $ [________________] | $ [________________] |
| TOTAL LIFE CARE PLAN (NOMINAL) | $ [________________] | $ [________________] |
SECTION 17: PRESENT VALUE CALCULATION
Economic Analysis:
Economist Name: [________________________________]
Date of Analysis: [__/__/____]
| Parameter | Value |
|---|---|
| Discount Rate Used | [____]% |
| Medical Inflation Rate | [____]% |
| Net Discount Rate | [____]% |
Present Value Summary:
| Category | Nominal Cost | Present Value |
|---|---|---|
| Total Life Care Plan Costs | $ [________________] | $ [________________] |
PRESENT VALUE OF LIFE CARE PLAN: $ [________________]
SECTION 18: NOTES AND ASSUMPTIONS
Key Assumptions:
[________________________________]
[________________________________]
[________________________________]
Cost Data Sources:
[________________________________]
[________________________________]
Limitations:
[________________________________]
[________________________________]
CERTIFICATION
I certify that this Life Care Plan Cost Summary is based on the life care plan prepared by [________________________________] dated [__/__/____] and represents a good faith summary of projected costs for settlement calculation purposes.
Signature: ________________________________________ Date: [__/__/____]
Print Name: [________________________________]
Title: [________________________________]
SOURCES AND REFERENCES
- International Academy of Life Care Planners Standards
- 4Structures.com: Life Care Plans in Personal Injury Cases
- Expert Institute: Establishing Damages in Life Care Plans
- Miller & Zois: Life Care Plans in Birth Injury Claims
This summary is for informational purposes only. A complete life care plan requires evaluation by a qualified life care planner. Present value requires economic analysis. Consult legal counsel regarding evidentiary requirements.
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Jurisdiction-Specific
This template is drafted for general use across all U.S. jurisdictions. State-specific versions with local statutory references are also available.
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Last updated: February 2026