MEPS-MPC-Hospital

OMB #: 0935-0108

Patient Request For 2005 Records

Please
send my
2005
Patient
Profile!

The customers named on the enclosed list
authorize and request you to supply a Patient
Profile for the Medical Expenditure Panel Survey.
Signed authorization forms are also enclosed.

Print a Patient Profile or other printout for all prescriptions filled or refilled in calendar
year 2005. Include this information for each prescription:
„

Date Filled or Refilled

„

Patient Payment

„

NDC*

„

Names of Third Party Payers

„

Quantity Dispensed

„

All Third Party Payment Amounts

*If the NDC is not available, please provide medicine name, manufacturer, strength, unit, and
dosage form.

Send the material to Westat, the data collection contractor for the study.
Mail to:

or

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

Fax to 1-800-292-6408

If you have any questions, call 1-800-318-3843.
Thank you for participating in this important study!
Sponsored by the U.S. Public Health Service
Conducted by WESTAT, a national research company

M:\7690\7690.19.04\MPC 2005\Forms\Pharm\2005 Pharm Patient Request.doc - 6/9/2006 - 2:38 PM - SH