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PATIENT LABEL
FORM ______ OF ______
MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
INSTITUTIONAL EVENT FORM
(NON-HOSPITAL FACILITIES)
FOR
REFERENCE YEAR 2005
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M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\IC NonHosp Event Form (NURSEHOME) (legal).DOC - 12/9/2005 - 12:05 PM lct
INSTITUTIONAL EVENT FORM
[COMPLETE ONE FORM FOR EACH STAY]
QUESTIONS 1 THROUGH 3: TO BE COMPLETED WITH MEDICAL RECORDS.
READ ONLY FOR FIRST STAY FOR THIS PATIENT: Someone in (PATIENT)'s family reported that (he/she) was a
patient in this facility during 2005.
MEDICAL RECORDS
1. What were the admit and discharge dates
of the (first/next) stay?
MO
DAY
YR
ADMIT:
______/______/______
DISCHARGE: ______/______/______
NOT YET DISCHARGED......................1
2a. I need the diagnoses for this stay. I
would prefer the ICD-9 codes (or DSM-IV
codes), if they are available.
CODE
DESCRIPTION
|__| ____________ ________________________________________
|__| ____________ ________________________________________
[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]
|__| ____________ ________________________________________
|__| ____________ ________________________________________
IF ONLY ONE DIAGNOSIS, GO TO Q3.
2b. Which of these was the principal
diagnosis?
IF MORE THAN ONE DIAGNOSIS:
CHECK BOX FOR PRINCIPAL DIAGNOSIS
CIRCLE '-8' IF PRINCIPAL
DIAGNOSIS NOT KNOWN............... -8
|__|__|__| . |__|__|
OFFICE USE ONLY
3. Please give me the name, specialty, and
telephone number of each physician who
provided services during the stay starting
on (ADMIT DATE) and whose charges
might not be included in the facility bill. We
are interested in physicians with whom
your facility has contractual arrangements,
not the patient's private physician.
[RECORD NAMES ON SEPARATELY BILLING DOCTOR FORM.
IF RESPONDENT IS NOT SURE WHETHER A PARTICULAR
DOCTOR'S CHARGES ARE INCLUDED IN THE FACILITY BILL,
RECORD INFORMATION FOR THAT DOCTOR ON SEPARATELY
BILLING DOCTOR FORM.]
DOES NOT HAVE THIS INFORMATION ..............................................0
SEPARATELY BILLING DOCTORS FOR THIS EVENT.......................1
NO SEPARATELY BILLING DOCTORS FOR THIS STAY ...................2
4a. Have we covered all of this patient's stays
during the calendar year 2005?
YES, ALL STAYS COVERED ...................
NO, NEED TO COVER ADDITIONAL
STAYS....................................................
4b. [IF ALL STAYS ARE RECORDED FOR
THIS PATIENT, REVIEW NUMBER OF
STAYS REPORTED BY
HOUSEHOLD.]
NO DIFFERENCE OR FACILITY
REPORTED MORE STAYS THAN
HOUSEHOLD.........................................
1 (Q4b)
2 (Q1-NEXT EVENT
FORM)
1 (ENDING FOR
MEDICAL RECORDS)
FACILITY RECORDED FEWER
STAYS.................................................... 2
PROBE: (PATIENT NAME) reported (NUMBER) stays at
(FACILITY) during 2005, but I have only recorded (NUMBER)
stays. Do you have any information in your records that
would explain this?
_______________________________________________________
_______________________________________________________
GO TO ENDING FOR MEDICAL RECORDS
ENDING FOR MEDICAL RECORDS:
GO TO NEXT PATIENT. IF NO MORE PATIENTS, THANK RESPONDENT AND END. THEN ATTEMPT
CONTACT WITH PATIENT ACCOUNTS OR ADMINISTRATIVE OFFICE.
.
1
QUESTIONS 5 THROUGH END: TO BE COMPLETED WITH PATIENT ACCOUNTS.
5. According to Medical Records, (PATIENT NAME)
was a patient in your facility during the period from
[ADMIT DATE] to [DISCHARGE DATE/END OF
2005]. Was the facility reimbursed for this stay on
a fee-for-service basis or a capitated basis?
[EXPLAIN IF NECESSARY:]
Fee-for-service means that the facility was
reimbursed on the basis of the services
provided.
FEE-FOR-SERVICE BASIS ....................
CAPITATED BASIS..................................
1
2 (Q21a)
Capitated basis means that the patient was
enrolled in a prepaid managed care plan, such
as an HMO, and reimbursement to the facility
was not based on the services provided.
[INTERVIEWER: IF IN DOUBT, CODE FEEFOR-SERVICE.]
BASIC CHARGES
6.
What was the full established charge for room,
board, and basic care for this stay, before any
adjustments or discounts, between [ADMIT
DATE] and [DISCHARGE DATE/END OF 2005]?
FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:
$_______________ . ________
[EXPLAIN IF NECESSARY:
The full
established charge is the charge maintained in
the facility's master fee schedule for billing private
pay patients. It is the “list price” for the service,
before consideration of any discounts or
adjustments
resulting
from
contractual
arrangements or agreements with insurance
plans. ]
(Q7)
CAN'T GIVE TOTAL CHARGE .......... 991 (Q10)
NO CHARGE ...................................... 992 (Q6A)
[IF NO CHARGE: Some facilities that don't
charge for each individual service do associate
dollar amounts with services in their records for
purposes of budgeting or cost analysis. This kind
of information is sometimes call a "charge
equivalent." Could you give me the charge
equivalent for this stay?]
6a. Why is there no charge for room, board, and basic
care for this stay?
FACILITY ASSUMES COST ....................
PREPAID TO CONTINUING CARE .........
STATE-FUNDED INDIGENT CARE
(NOT MEDICAID).................................
RELIGIOUS ORGANIZATION
ASSUMES COST.................................
VA FACILITY ............................................
OTHER (SPECIFY) ________________
GO TO Q14
2
1
2
3
4
5
6
7.
From what sources has the facility received payment for
these charges and how much was paid by each source?
IF NAME OF INSURER, PROBE: And is that Medicare,
Medicaid, or private insurance?
8. IF NOT VOLUNTEERED, ASK: And what was the total?
[IF NOT AVAILABLE, COMPUTE.]
a. Patient or patient’s family
$__________.____
b. Medicare
$__________.____
c. Medicaid
$__________.____
d. Private Insurance
$__________.____
e. VA
$__________.____
f. TRICARE/CHAMPVA/
CHAMPUS
$__________.____
g. WORKER'S COMP
$__________.____
h. OTHER (SPECIFY):
_____________________
$__________.____
TOTAL PAYMENTS
$__________.__
BOX 1
DO TOTAL PAYMENTS (Q8) EQUAL TOTAL CHARGES (Q6)?
YES...................................................1 (Q14)
NO.....................................................2 (Q9)
9. It appears that the total payments were (less than/more
than) the total charges. What is the reason for this
difference? [CODE 1 (YES) FOR ALL REASONS
MENTIONED.]
PAYMENTS LESS THAN CHARGES:
YES
Adjustment or discount
a. Medicare limit or adjustment .................... 1
b. Medicaid limit or adjustment .................... 1
c. Contractual arrangement with insurer
or managed care organization ............... 1
d. Courtesy discount .................................... 1
e. Insurance write-off ................................... 1
f. Worker’s Comp limit or adjustment.......... 1
g. Eligible veteran ........................................ 1
h. Other (Specify:) ___________________ 1
2
2
2
2
2
2
2
2
Expecting additional payment
i. Patient or Patient’s Family .......................
j. Medicare ..................................................
k. Medicaid...................................................
l. Private Insurance .....................................
m. VA ............................................................
n. TRICARE/CHAMPVA/CHAMPUS ...........
o. WORKER’S COMP .................................
p. Other (Specify:) ___________________
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
q. Charity care or sliding scale.................
r. Bad debt..................................................
1
1
2
2
PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment................................
t. Medicaid adjustment ................................
u. Private insurance adjustment ..................
v. Other (Specify:) ___________________
1
1
1
1
2
2
2
2
GO TO Q14
3
NO
10. Can you tell me what the facility's full established
daily rate for room and board and basic care was
during this stay?
10a. Why was there no charge for room, board, and
basic care for this stay?
$_______________ . ________
(Q11)
RATE CHANGED DURING STAY ..... 991 (Q12)
NO CHARGE ...................................... 992 (Q10A)
FACILITY ASSUMES COST ....................
PREPAID TO CONTINUING CARE .........
STATE-FUNDED INDIGENT CARE
(NOT MEDICAID).................................
RELIGIOUS ORGANIZATION
ASSUMES COST.................................
VA FACILITY ............................................
OTHER (SPECIFY) ________________
1
2
3
4
5
6
GO TO Q14
11.
For how many days was the patient charged
during this stay? (Please give only the days
during 2005.)
__________________ # DAYS
IF RESPONDENT CAN'T PROVIDE TOTAL DAYS, GO TO Q12.
OTHERWISE, CONTINUE.
11a. From what sources has the facility received payment for
these charges and how much was paid by each source?
IF NAME OF INSURER, PROBE: And is that Medicare,
Medicaid, or private insurance?
11b. IF NOT VOLUNTEERED, ASK: And what was the
total? [IF NOT AVAILABLE, COMPUTE.]
a. Patient or patient’s family
$__________.____
b. Medicare
$__________.____
c. Medicaid
$__________.____
d. Private Insurance
$__________.____
e. VA
$__________.____
f. TRICARE/CHAMPVA/
CHAMPUS
$__________.____
g. WORKER'S COMP
$__________.____
h. OTHER (SPECIFY):
_____________________
$__________.____
TOTAL PAYMENTS
$__________.__
GO TO Q14
4
12. Perhaps it would be easier if you gave me the information billing period by billing period.
BILLING PERIOD # ___
BILLING START DATE: _____/_____/_____
MO
DY
YR
BILLING END DATE: _____/_____/_____
MO
DY
YR
BILLING PERIOD #1
12-1. Between
IF # BILLED DAYS IS LESS THAN #
(BP DATES), how
many days was the DAYS IN BP, EXPLAIN:
patient charged for
room and board
and basic care?
______________
# BILLED DAYS
# DAYS IN BILLING PERIOD: _________
12-2. Between (BP DATES),
what was the private pay rate
for room and board and basic
care [PERSON] received? If
the rate changed, please give
me the first one.
$__________.____
12-6. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
12-3. How many
days would that
rate have applied
during this billing
period?
______________
# DAYS
GO TO Q12-6
Yes .... 1 (RECORD
RATE IN
Q12-8.)
No........2 (Q12-2A)
12-2A.
Between (BP DATES), what
other private pay rate applied
to the basic care that
[PERSON] received?
$__________.____
12-2B.
Between (BP DATES), what
other private pay rate applied
to the basic care that
[PERSON] received?
$__________.____
12-7
12-3A. On what
date did this rate
begin?
____/____/____
MO DY YR
12-4A. During this
billing period, how
many days would
that
rate
have
applied?
# DAYS: ________
DK ............... -8
12-3B. On what
date did this rate
begin?
____/____/____
MO DY YR
12-4B. During this
billing period, how
many days would
that
rate
have
applied?
# DAYS: ________
DK ............... -8
12-5A. Why did
the rate change?
CODE ONLY ONE.
LEVEL OF CARE ... 1
PATIENT
DISCHARGED:
TO HOSPITAL ..... 2
TO COMMUNITY . 3
TO OTHER
FACILITY .......... 4
RATE INCREASE .. 5
ROOM CHANGE.... 6
OTHER, SPECIFY . 7
_________________
12-5B. Why did
the rate change?
CODE ONLY ONE.
LEVEL OF CARE ... 1
PATIENT
DISCHARGED:
TO HOSPITAL ..... 2
TO COMMUNITY . 3
TO OTHER
FACILITY .......... 4
RATE INCREASE .. 5
ROOM CHANGE.... 6
OTHER, SPECIFY . 7
_________________
Yes .... 1 (Q12-7)
No........2 (Q12-2b)
12-6B. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
Yes .... 1 (Q12-7)
No........2 (RECORD
IN ANOTHER
BOOKLET)
Is (RATE IN 12-2/12-2A/12-2B) the private pay rate that applied at the end of the billing period?
YES .....................................................
NO .......................................................
12-8.
12-6A. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
1
2
(RECORD RATE IN Q12-8)
(ASK Q12-8)
What was the private pay rate that applied at the end of the billing period?
$______________._____
13. From what sources did the facility receive payments for
this billing period and how much was paid by each source?
[CODE ALL THAT APPLY]
5
a. Patient or patient’s family
$__________.____
b. Medicare
$__________.____
c. Medicaid
$__________.____
d. Private Insurance
$__________.____
e. VA
$__________.____
f. TRICARE/CHAMPVA/
CHAMPUS
$__________.____
g. WORKER’S COMP
$__________.____
h. OTHER (SPECIFY):
_________________
$__________.____
BILLING PERIOD #____
BILLING PERIOD # ___
BILLING START DATE: _____/_____/_____
MO
DY
YR
BILLING END DATE: _____/_____/_____
MO
DY
YR
12-1. Between
(BP DATES), how
many days was the
patient charged for
room and board
and basic care?
IF # BILLED DAYS IS LESS THAN #
DAYS IN BP, EXPLAIN:
______________
# BILLED DAYS
# DAYS IN BILLING PERIOD: _________
12-2. Between (BP DATES),
what was the private pay rate
for room and board and basic
care [PERSON] received? If
the rate changed, please give
me the first one.
$__________.____
12-6. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
12-3. How many
days would that
rate have applied
during this billing
period?
______________
# DAYS
GO TO Q12-6
Yes .... 1 (RECORD
RATE IN
Q12-8.)
No........2 (Q12-2A)
12-2A.
Between (BP DATES), what
other private pay rate applied
to the basic care that
[PERSON] received?
$__________.____
12-2B.
Between (BP DATES), what
other private pay rate applied
to the basic care that
[PERSON] received?
$__________.____
12-7
12-3A. On what
date did this rate
begin?
____/____/____
MO DY YR
12-4A. During this
billing period, how
many days would
that
rate
have
applied?
# DAYS: ________
DK ............... -8
12-3B. On what
date did this rate
begin?
____/____/____
MO DY YR
12-4B. During this
billing period, how
many days would
that
rate
have
applied?
# DAYS: ________
DK ............... -8
12-5A. Why did
the rate change?
CODE ONLY ONE.
LEVEL OF CARE ... 1
PATIENT
DISCHARGED:
TO HOSPITAL ..... 2
TO COMMUNITY . 3
TO OTHER
FACILITY .......... 4
RATE INCREASE .. 5
ROOM CHANGE.... 6
OTHER, SPECIFY . 7
_________________
12-5B. Why did
the rate change?
CODE ONLY ONE.
LEVEL OF CARE ... 1
PATIENT
DISCHARGED:
TO HOSPITAL ..... 2
TO COMMUNITY . 3
TO OTHER
FACILITY .......... 4
RATE INCREASE .. 5
ROOM CHANGE.... 6
OTHER, SPECIFY . 7
_________________
Yes .... 1 (Q12-7)
No........2 (Q12-2b)
12-6B. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
Yes .... 1 (Q12-7)
No........2 (RECORD
IN ANOTHER
BOOKLET)
Is (RATE IN 12-2/12-2A/12-2B) the private pay rate that applied at the end of the billing period?
YES .....................................................
NO .......................................................
12-8.
12-6A. LOOK AT
Q12-1. ARE ALL
BILLED DAYS
ACCOUNTED
FOR?
1
2
(RECORD RATE IN Q12-8)
(ASK Q12-8)
What was the private pay rate that applied at the end of the billing period?
$______________._____
13. From what sources did the facility receive payments for
this billing period and how much was paid by each source?
CODE ALL THAT APPLY
6
a. Patient or patient’s family
$__________.____
b. Medicare
$__________.____
c. Medicaid
$__________.____
d. Private Insurance
$__________.____
e. VA
$__________.____
f. TRICARE/CHAMPVA/
CHAMPUS
$__________.____
g. WORKER’S COMP
$__________.____
h. OTHER (SPECIFY):
_________________
$__________.____
ANCILLARY CHARGES
14. Did (PATIENT) have any health-related ancillary
charges for this stay? (That is, were there
charges for additional services not included in the
basic rate?)
15. What was the total of full established charges for
health-related ancillary care during this stay?
Please exclude charges for non-health related
services such as television, beautician services,
etc.
[Ancillaries are facility charges that are not
included in the basic charge. Ancillary charges
may include laboratory, radiology, drugs and
therapy (physical, speech, occupational).]
YES .........................
NO ...........................
1
2 (Q22)
TOTAL CHARGES:
$__________.___ (Q16)
l__l CHECK HERE IF RESPONDENT CAN'T SEPARATE
HEALTH AND NON-HEALTH RELATED ANCILLARY
CHARGES (Q16).
l__l CHECK HERE IF RESPONDENT CAN'T GIVE TOTAL
ANCILLARY CHARGES (Q19).
16. From what sources has the facility received payment for
these charges and how much was paid by each source?
IF NAME OF INSURER, PROBE: And is that Medicare,
Medicaid, or private insurance?
17. IF NOT VOLUNTEERED, ASK: And what was the total?
[IF NOT AVAILABLE, COMPUTE.]
a. Patient or patient’s family
$__________.____
b. Medicare
$__________.____
c. Medicaid
$__________.____
d. Private Insurance
$__________.____
e. VA
$__________.____
f. TRICARE/CHAMPVA/
CHAMPUS
$__________.____
g. WORKER'S COMP
$__________.____
h. OTHER (SPECIFY):
_____________________
$__________.____
TOTAL PAYMENTS
$__________.__
BOX 2
DO TOTAL PAYMENTS (Q17) EQUAL TOTAL CHARGES (Q15)?
YES...................................................1 (Q22)
NO.....................................................2 (Q18)
7
18. It appears that the total payments were (less than/more
than) the total charges. What is the reason for this
difference? [CODE 1 (YES) FOR ALL REASONS
MENTIONED.]
PAYMENTS LESS THAN CHARGES:
YES
Adjustment or discount
a. Medicare limit or adjustment .................... 1
b. Medicaid limit or adjustment .................... 1
c. Contractual arrangement with insurer
or managed care organization ............... 1
d. Courtesy discount .................................... 1
e. Insurance write-off ................................... 1
f. Worker’s Comp limit or adjustment.......... 1
g. Eligible veteran ........................................ 1
h. Other (Specify:) ___________________ 1
2
2
2
2
2
2
2
2
Expecting additional payment
i. Patient or Patient’s Family .......................
j. Medicare ..................................................
k. Medicaid...................................................
l. Private Insurance .....................................
m. VA ............................................................
n. TRICARE/CHAMPVA/CHAMPUS ...........
o. WORKER’S COMP .................................
p. Other (Specify:) ___________________
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
q. Charity care or sliding scale.................
r. Bad debt..................................................
1
1
2
2
PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment................................
t. Medicaid adjustment ................................
u. Private insurance adjustment ..................
v. Other (Specify:) ___________________
1
1
1
1
2
2
2
2
GO TO Q22
8
NO
19. Perhaps it would be easier if you gave me the information billing period by billing period.
BP1
a. First, what was the start date of the first billing period in which (PATIENT)
was a patient? ENTER MONTH ONLY IF BILLING PERIOD IS MONTHLY.
b. And what was the end date?
c. What was the total of full established charges for health-related ancillary
care during this billing period? Please exclude charges for non-health
related services such as television, beautician services, etc.
BP2
BP3
BP4
BP5
LAST BP
_____________
_____________
_____________
_____________
_____________
_____________
(MONTH) (Q19c)
(MONTH) (Q19c)
(MONTH) (Q19c)
(MONTH) (Q19c)
(MONTH) (Q19c)
(MONTH) (Q19c)
or
or
or
or
or
or
____/____/___
____/____/___
____/____/___
____/____/___
____/____/___
____/____/___
(START DATE)
(START DATE)
(START DATE)
(START DATE)
(START DATE)
(START DATE)
____/____/___
____/____/___
____/____/___
____/____/___
____/____/___
____/____/___
(END DATE)
(END DATE)
(END DATE)
(END DATE)
(END DATE)
(END DATE)
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
20. From what sources did the facility receive payments for ancillary charges for this billing period and how much was paid by each source?
a. Patient or patient’s family
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
b. Medicare
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
c. Medicaid
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
d. Private Insurance
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
e. VA
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
f. TRICARE/CHAMPVA/CHAMPUS
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
g. OTHER (SPECIFY):
_________________
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$_________.____
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
GO TO NEXT BP
GO TO Q22
9
CAPITATED BASIS
21a. What kind of insurance plan covered the patient for this
stay? Was it:
[IF NAME OF INSURER OR HMO, PROBE: And is that
Medicare, Medicaid, or private insurance?]
[CODE ALL THAT APPLY]
a.
b.
c.
d.
e.
f.
g.
YES
Medicare; ........................................... 1
Medicaid; ........................................... 1
Private Insurance;.............................. 1
VA; ..................................................... 1
TRICARE/CHAMPVA/CHAMPUS;.... 1
Worker’s Comp; or............................. 1
Something else? (SPECIFY:) ........... 1
______________________________
21b. What was the monthly payment from that plan?
$___________.__
21c. Was there a co-payment for any part of this stay?
YES.........................................................
NO...........................................................
21d. How much was the co-payment?
PROBE TO DETERMINE IF FOR DAY, WEEK, ETC.
$___________.__
NO
2
2
2
2
2
2
2
1
2(Q22)
per
DAY ............................. 1
WEEK .......................... 2
MONTH ....................... 3
OTHER ........................ 4
SPECIFY: ____________
DON'T KNOW............................................ 8
21e. For how many (days/weeks/months/other) was the
co-payment paid?
_______________#
DON'T KNOW............................................ 98
21f. Who paid the co-payment?
[IF NAME OF INSURER OR HMO, PROBE: And is that
Medicare, Medicaid, or private insurance?]
[CODE ALL THAT APPLY]
a.
b.
c.
d.
e.
YES
PATIENT OR PATIENT’S FAMILY ... 1
MEDICARE........................................ 1
MEDICAID ......................................... 1
PRIVATE INSURANCE ..................... 1
OTHER
(SPECIFY:) ___________________ 1
NO
2
2
2
2
21g. Do your records show any other payments for (this
visit/these visits)?
YES........................................................ 1
NO ......................................................... 2 (Q22)
21h. From what other sources has the facility received
payment for (this visit/these visits) and how much was
paid by each source?
a. Patient or patient’s family ...........
b. Medicare.....................................
c. Medicaid .....................................
d. Private Insurance........................
e. VA ...............................................
f. TRICARE/CHAMPVA/
CHAMPUS...................................
g. WORKER’S COMP ....................
h. OTHER (SPECIFY):
__________________________
[IF NAME OF INSURER OR HMO, PROBE: And
is that Medicare, Medicaid, or private insurance?]
22.
ARE THERE ANY ADDITIONAL STAYS FOR THIS
PATIENT TO BE ACCOUNTED FOR?
2
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
YES .......................... 1 (GO TO PATIENT
ACCOUNTS SECTION (Q5)
OF NEXT EVENT FORM.)
NO............................ 2 (GO TO NEXT PATIENT.
IF NO MORE PATIENTS,
THANK RESPONDENT AND
END.)
10
| File Type | application/pdf |
| File Title | .....MEDICAL EVENT FORM |
| Author | JACQUELYN SMITH |
| File Modified | 2005-12-09 |
| File Created | 2005-12-09 |