MEPS-HC Survey Instrument

OMB#: 0935-0108
PROVIDER LABEL

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR INSTITUTIONS

A1.

Hello, is this a long-term care facility?
NOTE: Include nursing homes, rehabilitation facilities, long-term units of hospitals (such as a Skilled
Nursing Facility or SNF unit).
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 hospital (but not long term care unit such as SNF), or ..............

HOSPITAL
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. Would you
transfer please?
NUMBER: (______)_____________________

EXT: __________

NAME (IF VOLUNTEERED): _______________________________

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\IC Contact Guide.DOC - 12/9/2005 - 12:05 PM - LA

A4.

Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Public Health Service. This is
a nationwide study about how people in the United States use and pay for health care. [NUMBER] of
your patients identified this facility as a source of health care during 2005 and signed authorization
forms 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(s). Would you or someone in your
office be able to provide this 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. Would you
be able to provide this information?
MEDICAL RECORDS CAN PROVIDE INFO ................................
NO, CONTACT BILLING SERVICE ..............................................
NO, CONTACT OTHER DEPARTMENT ......................................

A6.

1 (A7)
2
3 (A6a)

Would you please provide the following information about the Billing Service?
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

A6a.

I need the following information about the ________ department.
DEPARTMENT:

_________________________________

NAME:

_________________________________

TITLE:

_________________________________

TELEPHONE:

A7.

(______)_______________ EXT: ______

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 forms 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 RECORD(S) – FAX AUTHORIZATION
FORM(S) .....................................................................................
PREFERS MAILING RECORD(S) – MAIL AUTHORIZATION
FORM(S) ......................................................................................

A8.

1
2 (A9)
3 (A10)
4 (A9)
5 (A10)

COMPLETE EVENTS FORM(S) 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
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)

NAME: _____________________________________________
TITLE:______________________________________________
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 FORM(S)....................... 1
DIFFERENT FROM NAME WHO WILL RECEIVE FORM(S)/
MATERIAL(S) (RECORD:) ______________________________2
A11.

CODE ONE:
INSTITUTIONAL 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 record(s) to our office within two
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

4

A14.

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

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

PATIENT ACCOUNTS/OTHER DEPARTMENT/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) patients.
[READ IF NECESSARY: We are collecting information about the care these patients received from
(PROVIDER) during 2005. We would like to send you copies of the authorization forms from these
patients and then call back to collect the few pieces of information we need. May I FAX the forms to
you? (IF NOT: May I mail the forms 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
FORMS........................................................................................
PREFERS MAILING RECORDS – MAIL AUTHORIZATION
FORMS........................................................................................

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 forms for your files.
GO TO A18

5

A17.

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:) _____________________________________ .....

1
2

GO TO A19

A18.

Would you be the best person to receive the authorization forms?
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:) _____________________________________ .....

6

1
2

A19.

CODE ONE:
INSTITUTIONAL 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 forms 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 forms, we hope you can mail the records to our office within two
weeks. Thank you very much for your time and your help with this study. [END CONTACT]

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 forms
we (FAXED/sent)?
YES ...............................................................................................
NO AND WAS FAXED ..................................................................
NO AND WAS MAILED .................................................................

A23.

1 (A27)
2
3

Let me (FAX/send) the authorization form(s) to you ( again).
FAX ...............................................................................................
MAIL ..............................................................................................

7

1
2 (A25)

A24.

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: ___________________________________

A26.

ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

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...................................................

8

2 (A29)
3 (A30)

A28.

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 two weeks. Thank you very much for your time
and your help with this study. [END CONTACT]

9