MEPS-MPC-Hospital

OMB#: 0935-0108
PROVIDER LABEL

MEDICAL PROVIDER COMPONENT FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR PHARMACIES

1.

ASK IF NOT OBVIOUS: Have I reached (PHARMACY)?
CORRECT PHARMACY
VERIFY ADDRESS AND THEN CONTINUE WITH 2
PROBLEM WITH PHARMACY
RECORD INFORMATION BELOW, TERMINATE CALL,
AND CONSULT WITH A TASK COORDINATOR
__________________________________________________________________________
__________________________________________________________________________

2.

May I please speak to the pharmacist?
PHARMACIST AVAILABLE
CONTINUE WITH 3
PHARMACIST NOT AVAILABLE
END CONTACT

3.

Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Public Health Service. [NUMBER] of
your patients identified (PHARMACY) as a place where they received prescribed medicines during 2005. We
would like to send you a copy of the authorization forms they signed allowing us to contact you for information
about their prescriptions. We ask that you provide a Patient Profile or other printout for all prescriptions filled or
refilled for these patients during 2005. We ask that the printout include the NDC, date filled or refilled, quantity
dispensed with dosage form, the amount paid by the patient and the amount paid by any third party payers. We
would appreciate it if you could also include the types of the third parties.
May I FAX the authorization forms to you? (IF NOT: May I mail the forms to you?)
PHARMACY CAN PROVIDE INFORMATION:
CAN PROVIDE INFORMATION BEFORE RECEIVING AUTHORIZATION
FORM(S) ......................................................................................................................
FAX AUTHORIZATION FORM(S) BEFORE SEND/COLLECTING INFORMATION.......
MAIL AUTHORIZATION FORM(S) BEFORE SEND/COLLECTING INFORMATION .....

(4)
(5)
(6)

PHARMACY CANNOT PROVIDE INFORMATION:
NEED TO CONTACT CORPORATE OFFICE FOR AUTHORIZATION..........................
THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD VERBATIM) ...............................................................................................

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(11)

4.

[PHARMACY WILL PROVIDE ALL DATA NOW. WHEN INFORMATION COLLECTED FOR ALL PATIENTS
SAY:] Thank you very much for your time and help with this study. We will FAX you a copy of the authorization
forms for your files.
HAS FAX ..................................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL...........................................

5.

What is your FAX number?
FAX NUMBER: (________) __________________________________

5a.

And what name and title should I put on the FAX cover page?
NAME:

____________________________________________

TITLE:

____________________________________________

DEPARTMENT:____________________________________________
PHARMACY:

____________________________________________

GO TO 7

6.

Let me verify that I have the correct mailing address:
PHARMACY NAME: _______________________________________
DEPARTMENT:

_______________________________________

ADDRESS:

_______________________________________
_______________________________________

6a.

CITY:

______________ STATE: _______ ZIP: _______

TELEPHONE

(_________) ________________ EXT: _______

And to whom should this be addressed?
NAME: ___________________________________________________
TITLE: ___________________________________________________

2

1 (5)
2 (6)

7.

CODE ONE:
DATA FORM COMPLETE, NEED TO SEND AUTHORIZATION
FORM(S) ................................................................................................1
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING DATA ............2
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING DATA...........3
FAX AUTHORIZATION FORM(S) AND PHARMACY WILL SEND
DATA......................................................................................................4
MAIL AUTHORIZATION FORM(S) AND PHARMACY WILL SEND
DATA......................................................................................................5

8.

We will be sending you the authorization forms today. [END CONTACT]

9.

We will call you back shortly to collect the information.

(8)
(9)
(9)
(10)
(10)

What would be the best day and time to call?
DAY:______________ DATE: ______________ R’s TIME: _________________AM/PM
[END CONTACT AND RECORD FAX/MAIL DATE AND APPOINTMENT ON CONTACT PERSON
CALL RECORD.]

10.

After you receive the authorization forms, we hope you will complete the request and send it to our office within
two weeks. Our fax and address are included in the materials I’m sending. [END CONTACT].

11.

We will need to get in touch with the person or office that can provide the information we need. What is the name
of the person and/or office that we should contact and their telephone number?
PERSON’S NAME: _________________________________________
TITLE:

____________________________________________

NAME OF DEPARTMENT/OFFICE: ____________________________
TELEPHONE

12.

(_________) ________________ EXT: _______

Thank you very much for your help. [END CONTACT AND SEE A TASK COORDINATOR BEFORE MAKING
NEXT CONTACT.]

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