MEPS-MPC-Hospital

OMB #: 0935-0108

If faxing material, please use this as your cover sheet.
Cover Sheet Plus ________________ Page(s)

TO

_______________________________________________________________
Data Collection Specialist

FAX NUMBER

1-800-292-6408

FROM

________________________________________________________________
________________________________________________________________

DATE

_________________________________

If mailing material, please include this cover sheet in your envelope.
Please send to:

Anne Denbow
WESTAT
9274 Gaither Road, GA89
Gaithersburg, MD 20877-1420

OFFICE USE ONLY
Provider Name ________________________________________
ID/W ________________________________________________
Connected Case

Y _______

N _______

M:\7690\7690.19.04\MPC 2005\Forms\OB\2005 OB Return Form.doc - 6/9/2006 - 2:35 PM - SH