MEPS-HC Survey Instrument

OMB #: 0935-0108

DEPARTMENT OF HEALTH & HUMAN SERVICES

Agency for Healthcare
Research and Quality

We understand that one of our data collection coordinators has talked to you about the Medical Provider
Component of the Medical Expenditure Panel Survey that is being conducted for the Agency for
Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC),
both part of the U.S. Public Health Service. We wanted to take this opportunity to thank you for your
participation and tell you more about the study.
The objective of the study is to provide accurate information to government policymakers and private
researchers about the rapidly changing health care situation in this country. To accomplish this goal, we
have collected data from a cross-section of American households on how they used and paid for health
care during 2005. With the permission of members of these households, we are now contacting their
medical providers to determine the actual dates of service, the diagnoses, the services provided, the
amount that was charged, the amount that was paid, and the sources of payment. One or more of your
patients has given us permission to request this information from their medical and billing records.
The study materials enclosed with this letter include a list of your patients who have agreed to participate
in the survey and an authorization form for each patient.
This survey is authorized by section 902(a) of the Public Health Services Act [42 U.S.C. 299a].
Participation is voluntary, but we are depending on you to help us toward a more complete understanding
of the nation’s health care. The patient information we obtain will be used for research purposes only and
will be released publicly only in summary form in which establishments or individuals cannot be
identified. The confidentiality of patient information is protected by Federal Statute, Section 924(c) and
Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. This law prohibits
the release outside of the sponsoring agencies or their contractors of information that would permit
identification of a patient or establishment without first obtaining authorization from the patient or
establishment who gave the information.
A data collection coordinator from our contractor, Westat, will call shortly after you have received these
materials to see if you have any questions and, if convenient, to collect the information we need over the
telephone. If you have questions about the forms or procedures, call Westat, toll-free, at 1-800-792-3656.
Sincerely,

Carolyn Clancy, M.D.
Director
Agency for Healthcare Research and Quality

Edward J. Sondik, Ph.D.
Director
National Center for Health Statistics
Centers for Disease Control and Prevention

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