PROVIDER ID :	W	OMB#0935-0108
	PROVIDER NAME :
	MEDICAL PROVIDER COMPONENT
	LIST-INTERVIEWER VERSION
	PROVIDER  DIRECTORY  INFORMATION :	UPDATED  PROVIDER  INFORMATION :
	ADDRESS :	NAME:_______________________________________
	ADDRESS:____________________________________
	CITY :	STATE :	______________________________________________
	ZIP  :	CITY:________________________________________
	TELEPHONE :
	STATE:________ZIP:___________________________
	NOTES:
	TELEPHONE:(____)______________________________
	NOTES:______________________________________

	AS YOU REVIEW                        WITH THE PROVIDER, RECORD RESULTS.
	•	IF ANY DISAVOWALS, REVIEW INFORMATION ON THE                        DATA FORM TO SEE IF IT HELPS 	TO LOCATE THE                       IN THE PROVIDER'S FILE.
	REVIEW RESULTS :
	•	IF ANY                       LOCATED, CONTINUE WITH NEXT QUESTION IN CONTACT GUIDE.
	•	IF NO                         LOCATED (I.E.,ALL DISAVOWED), THANK RESPONDENT AND END CONTACT .
	CHECK BELOW	 NAME AND 	CHECK 	 CHECK BELOW AND 	RECORD 
	 IF PROVIDER 	BELOW IF 	EXPLAIN IF PROVIDER 	FINAL 
	DID NOT 	PROVIDER 	DOES NOT HAVE A 	RESULT 
	RECEIVE 	HAS A 	RECORD FOR THIS	FOR THIS
	FORM FOR THIS	RECORD 
	FOR THIS
	 [   ]	 [   ]	 [   ]	________________
	____________________
	IF ANY                        CHECKED ABOVE, RECORD DETAILS ON CALL RECORD AND NIRF.