MEPS-MPC-Hospital

OMB# 0935-0108

US Public Health Service
2005 Pharmacy Component

Patient Name:

Pharmacy:

Patient ID:

Pharmacy ID:

Data Form
A Part of the Medical Expenditure Panel Survey (MEPS)
Date Filled
/

NDC

/05

Quantity

Drug Name

Quantity Unit

Patient Payment

NDC

/05

Quantity

Patient Payment

NDC

/05

Quantity

Patient Payment

NDC

/05

Quantity

Manufacturer

Dosage Form

Type of 3rd Party Payer

.

Strength

Unit

3rd Party Payment
$

Drug Name

Quantity Unit

3rd Party Payment

.

$

/

Unit

-

Dosage Form

Date Filled

Strength

$
Drug Name

Quantity Unit

Type of 3rd Party Payer

.

$

/

Manufacturer

.

-

Dosage Form

Date Filled

Unit

3rd Party Payment
$

Drug Name

Quantity Unit

Type of 3rd Party Payer

.

$

/

Strength

-

Dosage Form

Date Filled

Manufacturer

Manufacturer

.

Strength

Unit

Patient Payment
$

.

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\Pharm Data Form.doc

Type of 3rd Party Payer

3rd Party Payment
$

.