MEPS-HC Survey Instrument

Medical Provider Component
M E D I C A L

E X P E N D I T U R E

P A N E L

S U R V E Y

HOSPITAL

Page 1 of 1

OMB # 0935-0108

Provider ID
Provider Name

Patient List
The patients listed below have given authorization to contact you and request information
from their records. Copies of the signed authorization forms are attached.
Each patient’s name, date of birth and gender are provided to help you to locate the patient in
your records.
For each patient, we will be asking about health care services received between January 1, 2005
and December 31, 2005. For each date of service, we will need information about diagnosis,
services provided, charges and payments.
A data collection coordinator will be calling you shortly after you have received these materials
to collect the information over the telephone.

Patient Name
1
2
3
4
5

Date of Birth

Sex