Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version

Confidential Customer Check List

Page X of Y

[FILL PROVIDER ID]

PROVIDER NAME:

Instructions

Thank you for taking the time to provide this medical billing information. We realize your time is valuable and limited. If you would like to contact us directly, please call [fill appropriate 800 number].

The customer(s) listed below have given us written authorization to contact you and request information from your records. Copies of the signed authorization forms are attached.

Step 1: Please Locate Medical Billing Records for Each Customer in Your Records: For each customer included in the Confidential Customer Checklist, please locate the following information on all services each customer received between January 1, 2009 and December 31, 2009:

Date filled NDC Quantity dispensed

Medicine name Payments and who made them (private insurance, Medicare, Medicaid, out-of-pocket, etc.)

Step 2: Please Record Outcome on the Confidential Customer Checklist: Please indicate whether you were able to locate the 2009 customer records, if you were able to locate the customer but there were no 2009 records, or if the individual is not a customer, by checking the appropriate box next to the customer in the Confidential Customer Checklist.

Step 3: Please Provide Information via Fax or Mail: Please assemble the information for all customers in the Confidential Customer Check List and fax or mail it to us, using the Fax or Mail Return Form. Please include the completed Confidential Customer List, with the appropriate box checked for each customer, in the package. If we do not hear from you, a data collection specialist will contact you to arrange for the collection of these data. If you would prefer to provide the medical billing information over the telephone we can arrange for the collection of these data at your convenience. Please call [FILL APPROPRIATE 800 NUMBER].

Page X of Y

[FILL PROVIDER ID]

PROVIDER NAME:

Confidential Customer Check List

Please use the check list below as a way to record the outcome of locating each customer record in your files, and include it when faxing or mailing your materials. If you choose to provide the medical billing information over the telephone, you may use this list as a reference tool for recording the outcome of locating each customer record in your files.

  REMINDER:  
IF RETURNING RECORDS BY FAX OR MAIL,
PLEASE INCLUDE THIS CHECKLIST FORM.

If faxing material, please fax to: If mailing material, please send to:

[FILL APPROPRIATE RTI-SSS MEPS-Medical Provider Component Director
NUMBER: 1-800-XXX-XXXX] One North Commerce Center

5265 Capital Boulevard

Raleigh, NC 27616

			CHECK ONE FOR EACH CUSTOMER:
Customer Name	Date of Birth	Gender	2009 Customer Records Located	Found Customer, No 2009 Records	Is Not A Customer
1.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
2.  [FILL NAME]	[FILL DOB]	[FILL M or F]			