MEPS-MPC-Hospital

OMB #: 0935-0108

Cover Sheet Plus ________________ Page(s)
TO

______________________________________________________________________

PROVIDER

______________________________________________________________________

FAX NUMBER

FROM
ITEMS SENT

_________________________________

DATE

__________________________________

PHONE NUMBER
FAX NUMBER
DIRECT LINE

‰ Authorization Form(s)
‰ Patient List

_________________________

‰ Letter
‰ Brochure

Patient Record File Number

___________________________

Patient Account File Number

___________________________

800-792-3656
800-792-3670
________________

‰ Fax/Mail Return Form

Thank you for participating in this important study!
If you do not receive all pages or transmission is unclear, please call 800-318-3843.
This message is intended for the sole use of the individual or entity to which it is addressed and may contain information
that is proprietary, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the
intended recipient or is not responsible for delivering the message to the intended recipient, you are hereby notified that
any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this
communication in error, please notify Westat immediately by telephone at 1-800-792-3656 and return the original
message to us at the above address by return mail. We will reimburse any costs you incur in notifying us and returning
the facsimile to us. Thank you.
Public reporting burden for the collection of information is estimated to average 5 minutes per patient. Any comments
regarding this burden or estimate or any other aspect of this collection of information including suggestions for
reducing this burden should be sent to: Report Clearance Office, Attention: PRA, United States Public Health Service.
Paperwork Reduction Project (0935-0098), Hubert Humphrey Building, Room 737F, 200 Independence Avenue, SW,
Washington, DC 20201.

For additional information log on to http://www.MEPS.AHRQ.gov.
OFFICE USE ONLY
Provider Name ________________________________________
ID/W ________________________________________________
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