MEPS-HC Survey Instrument

OMB#: 0935-0108

PROVIDER LABEL

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR HOSPITALS

A1.

Hello, is this a hospital, outpatient department, satellite clinic, or surgi-center?
YES ...............................................................................................
NO ...............................................................................................

A2.

1 (A3)
2

How would you describe this facility? Is this:
A doctor’s office;............................................................................
A publicly-funded clinic;.................................................................
An urgi-center;...............................................................................

A3.

OFFICE-BASED
PROVIDER CONTACT
GUIDE

A health maintenance organization (HMO);..................................

(TERMINATE AND
CONSULT TASK
COORDINATOR)

A home health provider; ................................................................

HOME HEALTH
CONTACT GUIDE

A long term care facility such as a nursing home; or ....................

INSTITUTION
CONTACT GUIDE

Something else? (SPECIFY:) ___________________________
___________________________________________________

(TERMINATE AND
CONSULT TASK
COORDINATOR)

I need to speak to a person who handles requests for the release of Medical Records. Can you
transfer me?
NUMBER: (______)_____________________

EXT: __________

NAME (IF VOLUNTEERED): _______________________________

1
M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\Hosp Contact Guide.DOC - 12/9/2005 - 12:04 PM - dr

A4.

Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Public Health Service.
[NUMBER] of your patients identified this facility as a source of health care during 2005 and signed
authorization form(s) allowing us to contact you for information about their care. We need the dates of
service, the diagnosis, and the names of the physicians who treated the patient. Would you or
someone in your office be able to provide this type of information?
YES ...............................................................................................
NO ...............................................................................................

A4a.

1 (A5)
2

Who would we contact to obtain this information?
NAME:

_________________________________

TITLE:

_________________________________

DEPARTMENT:

_________________________________

NAME OF SERVICE: _________________________________
TELEPHONE:

A5.

(______)_______________ EXT: ______

We also need information regarding the types of services provided, the amounts charged for these
services before any adjustments or discounts, and the sources and amounts of payment. Can you
provide this information?
MEDICAL RECORDS CAN PROVIDE INFO ................................
NO, CONTACT BILLING SERVICE ..............................................
NO, CONTACT OTHER DEPARTMENT ......................................

A6.

1 (A7)
2
3

Who could we contact to obtain this information?
NAME:

_________________________________

TITLE:

_________________________________

DEPARTMENT:

_________________________________

NAME OF BILLING SERVICE: __________________________
TELEPHONE:

(______)_______________ EXT: ______

CODE ONE:
A4 = 1 ............................................................................................
A4 = 2 ............................................................................................

1
2 CONTACT OTHER
DEPARTMENT. Thank
you very much for your
help. [END CONTACT
AND CALL NEW
NUMBER]

2

A7.

We would like to send you a copy of the authorization form(s) and then call back to collect the
information. May I FAX the form(s) to you? (IF NOT: May I mail the form(s) to you?)
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S).....................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
PREFERS MAILING RECORDS–FAX AUTHORIZATION
FORM(S) ...................................................................................
PREFERS MAILING RECORDS–MAIL AUTHORIZATION
FORM(S) ...................................................................................

A8.

2 (A9)
3 (A10)
4 (A9)
5 (A10)

[COMPLETE EVENTS FORMS NOW. WHEN ALL FORMS HAVE BEEN COMPLETED, SAY:]
Thank you very much for your time and your help with this study. We will FAX you a copy of the
authorization form(s) for your files.
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

A9.

1

1
2 (A10)

What is your FAX number?
FAX NUMBER: (_______) _____________________________

A9a.

And what name and title should I put on the fax cover page?
NAME:
_____________________________________
TITLE:
_____________________________________
DEPARTMENT: _____________________________________

A9b.

RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE .................................... 1
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD:) _________________________________________ 2

GO TO A11

3

A10.

Would you be the best person to receive the authorization form(s)?
YES ...............................................................................................

1 (VERIFY NAME, TITLE,

NO ...............................................................................................

2 (OBTAIN NAME, TITLE,

AND DEPARTMENT)
AND DEPARTMENT)

A10a. Let me also verify that I have the correct mailing address:
NAME:

________________________________

TITLE:

________________________________

DEPARTMENT:

________________________________

INSTITUTION NAME: ________________________________
ADDRESS:

________________________________
________________________________

CITY:

__________ STATE: ______ ZIP: ____

TELEPHONE:

(______)_______________ EXT: ____

A10b. RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORMS .........................
DIFFERENT FROM NAME WHO WILL RECEIVE
FORMS/MATERIALS (RECORD:) ___________________......
A11.

1
2

CODE ONE:
HOSPITAL EVENT FORM(S) COMPLETE ..................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
RESPONDENT WILL MAIL RECORDS........................................

1
2 (A12)
3 (A12)
4 (A13)

A11a. We will be sending you the authorization form(s) today. Thanks again. [END CONTACT]
A12.

We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX/MAIL DATE AND
APPOINTMENT ON CALL RECORD.]

A13.

After you receive the authorization form(s), we hope you can mail the records to our office within 2
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

A14.

INTERVIEWER: IS THE MEDICAL RECORD INFORMATION COLLECTED AND DO YOU NEED TO
CALL PATIENT ACCOUNTS OR OTHER DEPARTMENT IN THE HOSPITAL OR A BILLING
SERVICE?
YES................................................................................................
NO .................................................................................................
ALL INFORMATION COMPLETE .................................................

4

1 (A15)
2 (A22)
3 (END CONTACT)

PATIENT ACCOUNTS/ BILLING SERVICE
INTRODUCTION
A15.

Hello, my name is (YOUR NAME). We are conducting the Medical Expenditure Panel Survey for the
U.S. Public Health Service. The survey is about how people in the United States use and pay for
health care. We were referred to you by (CONTACT PERSON/PROVIDER) for information about
(NUMBER) patient(s).
[READ IF NECESSARY: We are collecting information about the care this/these patient(s) received
from (PROVIDER) during 2005. We would like to send you copies of the authorization form(s) from
this/these patient(s) and then call back to collect the few pieces of information we need. May I FAX
the form(s) to you? (IF NOT: May I mail the form(s) to you?)]
IF ASKED WHAT TYPE OF INFORMATION WE NEED: For each date of service, we need
information about diagnosis, services provided, charges, and payments.
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S).....................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
PREFERS MAILING RECORDS-FAX AUTHORIZATION
FORM(S) ...................................................................................
PREFERS MAILING RECORDS-MAIL AUTHORIZATION
FORM(S) ...................................................................................

A16.

1
2 (A17)
3 (A18)
4 (A17)
5 (A18)

[COMPLETE EVENTS FORMS NOW. WHEN ALL FORMS HAVE BEEN COMPLETED, SAY:]
Thank you very much for your time and your help with this study. We will send you a copy of the
authorization form(s) for your files.

CODE ONE:

A17.

FAX AUTHORIZATION FORM(S).................................................

1

MAIL AUTHORIZATION FORM(S) ...............................................

2 (A18)

What is your FAX number?
FAX NUMBER: (_______) _____________________________

A17a. And what name and title should I put on the fax cover page?
NAME:
_____________________________________
TITLE:
_____________________________________
DEPARTMENT: _____________________________________
A17b. RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE ....................................
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD:) _____________________________________ .....
GO TO A19

5

1
2

A18.

Would you be the best person to receive the authorization form(s)?
YES ...............................................................................................

1 (VERIFY NAME, TITLE,

NO ...............................................................................................

2 (OBTAIN NAME, TITLE,

AND DEPARTMENT)
AND DEPARTMENT)

A18a. Let me also verify that I have the correct mailing address.
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

A18b. RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORMS .........................
DIFFERENT FROM NAME WHO WILL RECEIVE
FORMS (RECORD:) ___________________ ...........................

A19.

1
2

CODE ONE:
EVENT FORM(S) COMPLETE .....................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA .........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA .........................................................................................
RESPONDENT WILL MAIL RECORDS........................................

1
2 (A20)
3 (A20)
4 (A21)

A19a. We will be sending you the authorization form(s) today. Thanks again. [END CONTACT]

A20.

We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX/MAIL DATE AND
APPOINTMENT ON CALL RECORD.]

A21.

After you receive the authorization form(s), we hope you can mail the records to our office within 2
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

6

FOLLOW-UP INTRODUCTION
A22.

May I please speak to (RESPONDENT)?
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey,
which we are conducting for the U.S. Public Health Service. Did you receive the authorization form(s)
we (FAXED/sent)?
YES ...............................................................................................
NO AND WAS FAXED ..................................................................
NO AND WAS MAILED .................................................................

A23.

Let me (FAX/send) the authorization form(s) to you ( again).
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

A24.

1 (A27)
2
3

1
2 (A25)

I would like to verify your name and FAX number. I have (NAME AND FAX NUMBER FROM A9a). Is
that correct?
FAX NUMBER:
NAME:
TITLE:
DEPARTMENT:

(_______) _____________________________
_____________________________________
_____________________________________
_____________________________________

We will FAX the materials to you and call back shortly to collect the information. What would be the
best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help.
APPOINTMENT ON CALL RECORD.]

A25.

[END CONTACT AND RECORD FAX DATE AND

I would like to verify your name and address. I have (NAME AND ADDRESS FROM A10a). Is that
correct? [MAKE CORRECTIONS AS NECESSARY]
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

7

A26.

What would be the best day and time to call you back? (ALLOW ONE WEEK FOR RECEIPT OF
MAIL.)
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD MAIL DATE AND APPOINTMENT
ON CALL RECORD.]

A27.

If it is convenient for you, we can just go ahead and complete the data forms together over the phone
right now. I’d be happy to hold on while you get the information you need from your records.
WILL COMPLETE BY PHONE NOW ............................................
WILL COMPLETE BY PHONE IN THE FUTURE .........................
PREFERS MAILING RECORDS...................................................

A28.

1
2 (A29)
3 (A30)

COMPLETE EVENT FORMS NOW.
WHEN ALL FORMS HAVE BEEN COMPLETED, SAY: Thank you very much for your time and your
help with this study. [END CONTACT]

A29.

What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD APPOINTMENT ON CALL
RECORD.]

A30.

OMITTED

A31.

We hope you can mail the records to our office within 2 weeks. Thank you very much for your time
and your help with this study. [END CONTACT]

8

FOLLOW-UP INTRODUCTION (if necessary)
A32.

May I please speak to (RESPONDENT)?
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey,
which we are conducting for the U.S. Public Health Service. Did you receive the authorization form(s)
we (FAXED/sent)?
YES ...............................................................................................
NO AND WAS FAXED ..................................................................
NO AND WAS MAILED .................................................................

A33.

Let me (FAX/send) the authorization form(s) to you ( again).
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

A34.

1 (A37)
2
3

1
2 (A35)

I would like to verify your name and FAX number. I have (NAME AND FAX NUMBER FROM A9a). Is
that correct?
FAX NUMBER:
NAME:
TITLE:
DEPARTMENT:

(_______) _____________________________
_____________________________________
_____________________________________
_____________________________________

We will FAX the materials to you and call back shortly to collect the information. What would be the
best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help.
APPOINTMENT ON CALL RECORD.]

A35.

[END CONTACT AND RECORD FAX DATE AND

I would like to verify your name and address. I have (NAME AND ADDRESS FROM A10a). Is that
correct? [MAKE CORRECTIONS AS NECESSARY]
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

9

A36.

What would be the best day and time to call you back? (ALLOW ONE WEEK FOR RECEIPT OF
MAIL.)
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD MAIL DATE AND APPOINTMENT
ON CALL RECORD.]

A37.

If it is convenient for you, we can just go ahead and complete the data forms together over the phone
right now. I’d be happy to hold on while you get the information you need from your records.
WILL COMPLETE BY PHONE NOW ............................................
WILL COMPLETE BY PHONE IN THE FUTURE .........................
PREFERS MAILING RECORDS...................................................

A38.

1
2 (A39)
3 (A41)

COMPLETE EVENT FORMS NOW.
WHEN ALL FORMS HAVE BEEN COMPLETED, SAY: Thank you very much for your time and your
help with this study. [END CONTACT]

A39.

What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD APPOINTMENT ON CALL
RECORD.]

A40.

OMITTED

A41.

We hope you can mail the records to our office within 2 weeks. Thank you very much for your time
and your help with this study. [END CONTACT]

10

ADMINISTRATIVE OFFICE OR MEDICAL STAFFING
HAVE CONTACT NAME Æ May I please speak to (NAME)?
DO NOT HAVE CONTACT NAME Æ May I please speak to someone in the administrative office?
INTRODUCTION
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey for
the U.S. Public Health Service. The survey is about how people in the United States use and pay for
health care. (We were given your name by (NAME) in the (NAME OF REFERRING DEPARTMENT)/I
need to speak to someone who knows which physicians are staff physicians and which have staff
privileges at this facility.)
Earlier, your medical records department gave us information about the care that some of our study
patients received at your facility and the names of the physicians who provided that care. Now we
need information on whether the charges for these physicians' services would be included in the
hospital's bill or billed separately by the physician.
B1.

As I give you the names of the physicians I have, can you tell me which ones' services were included
in the hospital bill?
WILL COMPLETE BY PHONE NOW ............................................
WILL COMPLETE BY PHONE IN THE FUTURE .........................
CANNOT PROVIDE THE INFORMATION....................................

B2.

REVIEW SBD LISTS.
INFORMATION PROVIDED FOR ALL SBDs LISTED .................
Thank you very much for your help. [END CONTACT]
INFORMATION NOT PROVIDED FOR ALL SBDs LISTED.........

B3.

1
2 (B3)
3 (B4)

1
2 (B4)

What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD APPOINTMENT ON CALL
RECORD.]

B4.

Please give me the name and telephone number of the person who can provide that information.
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

TELEPHONE:

(______)_______________ EXT:________

Thank you very much for your help. [END CONTACT]

11