MEPS-MPC-Office Based

NODE ID:
PROVIDER ID:

___________________________________
|___|___|___|___|___|___|

PROVIDER NAME: ___________________________________
HOST NAME:

___________________________________

HOST ID:

___________________________________

PATIENT NAME:

___________________________________

EVENT TYPE:

___________________________________

EVENT DATE:

_____/_____/_____ (to _____/_____/_____)

GLOBAL FEE CONTINUATION SHEET
FOR
SEPARATELY BILLING DOCTORS FOR REFERENCE YEAR 2005

M:\7690\7690.19.04\MPC 2005\Forms\SBD\SBD B2b ContSheet.doc - 1/26/2006 - 12:01 PM - SH

B2b. What other dates of service were covered by this global
fee? Please include dates before or after 2005 if they
were included in the global fee.

MO DAY
YR
TYPE
____/____/______ _____
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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___________________
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M:\7690\7690.19.04\MPC 2005\Forms\SBD\SBD B2b ContSheet.doc - 1/26/2006 - 12:01 PM - SH
____/____/______ _____
___________________

IF TYPE 96, SPECIFY:
|__|__|
OFFICE
USE
ONLY

B2c. Did (PATIENT NAME) receive the services on (DATE)
in a:
Physician's Office (TYPE=MV);
Hospital as an Inpatient (TYPE=SH);
Hospital Outpatient Department (TYPE=SO);
Hospital Emergency Room (TYPE=SE); or
Somewhere else (TYPE=96)?