Attachment 21 -- HC MEPS Record Keeper

Attachment 21 -- HC MEPS Record Keeper.pdf

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Attachment 21 -- HC MEPS Record Keeper

OMB: 0935-0118

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0118 can be found here:
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23299.1107.76905201
OMB #0935-0118

08-450

Doctors

Hospitals

Pharmacies

OTHER

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YOUR
Health Care
Information

Instructions
You may use this record keeper to
help prepare for your future MEPS
interviews. For each health care event
record the following information:
•	 household member’s name
•	 date of the visit or phone call
•	 health care provider
•	 reason for the visit or phone call
•	 any payment information
•	 any medications prescribed
On the back of the record keeper
there is space to record your health
care providers’ contact information.

Name _________________________________

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Prescriptions ____________________________ 	

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Prescriptions ____________________________ 	

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Name _________________________________

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Payment _______________________________

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Prescriptions ____________________________

Prescriptions ____________________________

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File Type	application/pdf
File Modified	2009-07-16
File Created	2008-10-15