Form 1 NAMCS-1 Physician Induction Interview (Line 1)

OMB No. 0920-0234: Expiration date 07/31/2012

Patient Record
number

Part 3 — Missing Patient
Record Form
Items (1–13)

Item
number(s)

Comments

(b)

(c)

(a)

NOTICE - Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

List missing items, and refer
to the FR manual for
guidelines on retrieving
missing information.

Assurance of Confidentiality - All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be
used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to
other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the
Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

1. Physican’s address:

NAMCS-1

FORM
(12-8-2009)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

RECORD ON CONTROL CARD

NATIONAL CENTER FOR HEALTH STATISTICS
CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL AMBULATORY
MEDICAL CARE SURVEY
2010 PANEL
2. Physician’s telephone and FAX numbers (Area code and number)
Office
1

45. Was provider/office staff contacted for any reason during the editing process?
Yes

No

RECORD ON CONTROL CARD

FAX

RECORD ON CONTROL CARD

TO
Month

Office Telephone
2
FAX

RECORD ON CONTROL CARD
RECORD ON CONTROL CARD

3. Progress Record

46. For all Final = 1 cases, transfer information from front of Patient Record Folio.
FROM

Telephone

Day

Activity

Month

Date Completed

FR Code

Notes

Day

Telephone Screener
WEEK OF –
Induction Interview
SURVEY WEEK
Complete a Patient
Record for patient
SW

Mon.

Tues.

Wed.

Thur.

Fri.

Sat.

Sun.

Total

Final Disposition and Summary
Number
of patient
visits

Section I – TELEPHONE SCREENER

4. Record of telephone calls

and
every

TE

nth
patient thereafter.

Patient Record Forms Completed

Call

Number
of
records
completed

Date

Time

1
2

NOTES

3
4
5
6
7
8
9

Page 24

Results

FORM NAMCS-1 (12-8-2009)

USCENSUSBUREAU

RECORD ON
CONTROL CARD

FR INSTRUCTION

If interview is with a CHC provider, start with Section II on page 7, but remember
to complete the office hours on page 5. If CHC provider refuses to complete the
survey, obtain answers to item 13 in Section I, on page 6.

Section VI – MISSING INFORMATION CHART
Part 1 — Missing Patient
Record Forms

44a. Enter 7-digit Patient Record number(s) for missing forms.

5a. Has the physician moved out of the United States?
1
2

Yes – SKIP to CHECK ITEM A on page 6
No

b. Is the physician retired or deceased?
1
2

b. Contact provider regarding missing forms. Enter results of missing forms

Yes – SKIP to CHECK ITEM A on page 6
No

follow-up below:

6. Introduction
Forms/information obtained
Forms/information not obtained – Explain why

Hello, Dr. . . ., I am (Your name). I’m calling for the Centers for Disease Control and
Prevention regarding their study of ambulatory care. You should have received a letter
from the Director of the National Center for Health Statistics, explaining the study. (Pause)
You’ve probably also received a letter from the Census Bureau. We are acting as data
collection agents for the study.
IF DOCTOR DOES NOT REMEMBER NCHS LETTER; THE LETTER STATES:
The Centers for Disease Control and Prevention’s National Center for Health
Statistics (NCHS) is conducting the National Ambulatory Medical Care Survey
(NAMCS). This annual study, which has been in the field since 1973, collects
information about the large portion of ambulatory care provided by physicians
and mid-level providers throughout the United States. Research utilizing the
NAMCS helps to inform physicians, health care researchers, and policy makers
about the changing characteristics of ambulatory health care in this country.
The information that will be requested includes data about the patient visit
(e.g., demographics, diagnoses, services, and treatments), physician practice
characteristics (e.g., practice type), and the use of electronic medical records.
Many organizations and leaders in the health care community, including those
providing the enclosed letter of endorsement, have expressed their support
and join me in urging your participation in this meaningful study. You will be
asked to complete a one-page questionnaire on a sample of about 30 patient
encounters during a randomly assigned one-week reporting period.
Additionally, there is a short interview (approximately 35 minutes) with you
about the nature of your practice. Participation is voluntary. The following are
some key points about the survey:
• Data collection for the NAMCS is authorized by Section 306 of the Public
Health Service Act (Title 42, U.S. Code, 242k).

Part 2 — Missing Days or
Blocks of Time
List day(s) and blocks of time
not reported, and check with
the provider’s office for the
reason. (If patients were
seen during day(s)/hours not
reported, arrange to obtain
missing data. If not possible
to obtain missing data, ask
for the number of
patients seen during
day(s)/hours not reported.)

Not reported
Day(s)

Blocks of
time

Reason

(a)

(b)

(c)

Will physician’s
office provide Number
of
missing data?
patients
(Mark X)
seen
(d)
Yes

No

(e)

• All information collected will be held in the strictest confidence according
to Section 308(d) of the Public Health Service Act (42, U.S. Code,
242m(d)) and the Confidential Information Protection and Statistical
Efficiency Act (Title 5 of PL 107-347). This information will be used for
statistical purposes only. No patient names, social security numbers, or
addresses are collected.
• This study conforms to the Privacy Rule as mandated by HIPAA, because
disclosure of patient data is permitted for public health purposes, and
the NCHS Research Ethics Review Board has approved NAMCS.
• U.S. Census Bureau employees, who administer the study, have taken an
oath to abide by Title 13, U.S. Code, Section 9, which requires them to
keep all information about your practice and patients confidential.
NOTES
A representative of the Census Bureau, acting as our agent, will be calling you
to schedule an appointment regarding the details of your participation. If you
have any questions regarding your participation, please call a NAMCS
representative at (800) 392-2862. Additional information on the survey may be
obtained by visiting the NAMCS participant Web site at www.cdc.gov/namcs.
We greatly appreciate your cooperation.
Page 2

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 23

Section V – PATIENT RECORD FORM CHECK
CHECK ITEM D

Section I – TELEPHONE SCREENER – Continued

7. Specialty

1. Who answered the questions in the Physician Induction Interview?
Mark (X) all that apply.
1
Sampled provider
3
Other – Specify
Office staff
2

a. Your specialty is _______________________________ ,
1

is that right?
2. Who completed the Patient Record forms?
Mark (X) all that apply.
1
Sampled provider
4
Other – Specify
Office staff
2
3
FR – abstraction

2

2

practice)?
(Name of specialty)
Code
Refer to the NAMCS-21, pages 3 and 4 for codes.

Yes
No

4. If the FR abstracted the PRFs, were the Accounting Documents placed in each of the medical records
used for abstraction?
1
2

FR INSTRUCTION

Yes
No – Explain

c. What is your ethnicity?
d. What is your race?
Mark (X) one or more.

5. Did sampled provider (or staff) request to see the IRB approval?
1
Yes
No
2
NOT call the sampled provider regarding missing information on Patient Record form
unless instructed by your supervisor or the FR Manual.

1

1
2
3
4
5

Mark (X) when completed
Field
Representative
check list

Office
check
list

(a)

(b)

8.

Edit

Do not classify cases solely on the basis of specialty. Complete
all items on the NAMCS-1 and have the physician fill out PRFs if
appropriate.
2

43. Verify that all items on the Patient Record form check list have been answered. DO

Edit

b. What is your specialty (including general

3. Did the sampled provider accept the Data Use Agreement?
1

Yes – SKIP to item 8
No

Which of the following categories best
describes your professional activity –
patient care, research, teaching,
administration, or something else?

1
2
3
4

a. Check for missing Patient Record forms (e.g., if the last completed Patient Record

5

Hispanic or Latino
Not Hispanic or Latino
White
Black/African-American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaska Native

Patient care
Research
Teaching
Administration
Something else – Specify

is number 1500051, do you have 1500001 through 1500050). List missing Patient
Record forms in Section VI, Part I of chart.
b. Item 1a – Date of visit recorded on each Patient Record form – If missing,
complete 1 and 2 below.
(1) Determine date of visit by referring to Patient Record forms immediately before
and after. For example, if 1550087 through 1550092 are dated "1/12/2009" and
the date on 1550088 is missing, enter "1/12/2009" in item 1a.

9a. Do you directly care for any ambulatory
patients in your work?

3

c. Items 1–13 –Verify that each of these items has been answered on the Patient

b. PROBE: We include as ambulatory patients,

Record form. List missing information in Section VI, Part 3 of chart on page 24. If
folio B was used, make sure item 14, laboratory values, was completed accuraterly.

any patients coming to see you for personal
health services who are not currently on
the premises. Does your work include any
such individuals?

d. Check the sample provider’s office schedule against the dates on the Patient
Record forms for survey week days with no completed Patient Record
forms. Do the dates on the Patient Record forms include every day during the
survey week that the sample provider’s office scheduled appointments?
Yes

1
2

(2) If the exact date of the patient visit cannot be determined, estimate the date
and enter "EST" next to the entry.

1
2

c. Are you employed by the Federal

No –List missing days in Section VI, Part 2 of chart on page 23.

Government or do you work in a hospital
emergency or outpatient department?

NOTES

1
2

d. In addition to working in any of these
settings, do you also see any ambulatory
patients?

1
2

Yes – SKIP to item 9c
No – does not give direct care [9b PROBE]
No longer in practice – SKIP to item 11 on page 4

Yes, cares for ambulatory patients
No, does not give direct care –Determine
reason, then read item 11 on page 4

Yes
No – SKIP to item 10a on page 4
Yes
No – SKIP to item 11 on page 4

If "Yes" to item 9d, all of the following questions
are concerned with the private patients.
Page 22

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 3

Section IV – DISPOSITION AND SUMMARY

Section I – TELEPHONE SCREENER – Continued

10a. We have your address as (Read address shown
1

in item 1). Is that the correct address for your
office?

b. What is the (correct) address and telephone

2

40. FINAL DISPOSITION

Yes – SKIP to item 12
No, incorrect address – Ask item 10b

(a) Eligible physician/provider

}

Number and street

number of your office?

RECORD ON CONTROL CARD
City

RECORD ON CONTROL CARD
State

ZIP Code

RECORD ON CONTROL CARD
Telephone (Area code and number)

RECORD ON CONTROL CARD

11.

12.

1

Completed Patient Record forms

2

Out-of-scope (Item 35,
codes 2, 3, 4, 5, 6, 8, 9, or 10)
Refused-Breakoff (Item 35,
code 1)
Unavailable during
reporting period (Item 35,
code 11)
Moved out of PSU (Item 35,
code 12–final)
Can’t locate (Item 35
code 7)

3
4

SKIP to
item 12

5
6

Day

Year

➜

2. Number of days during
reporting week on which
patients were seen . . . . . . . .

End of Interview
–Make certain
all items are
accurately
completed
before returning
materials to the
office.

7

Less than 3 providers sampled

8

Parent CHC Out-of-scope

9

Parent CHC Refused to participate

3. Number of patient record
forms completed . . . . . . . . . .
NOTE – For items 41(1) and 41(3),
see FR instruction below.

(c) Transfer cases
Moved out of PSU (Item 35,
code 12 –pending)
Edit

I would like to arrange an appointment with you within the next week or so to discuss
the study. It will take about 30 minutes. What would be a good time for you, before
Friday,________________(last Friday before the assigned reporting week)?
Month

}

1. Number of patient visits
during reporting week . . . . . .

(b) Unused CHC NAMCS-1

Thank you, Dr. . . ., but I believe that since you do not (see any ambulatory
patients/practice any longer), our questions would not be appropriate for you. I
appreciate your time and interest. (Go to Check Item A on page 6.)

Weekday

41. CASE SUMMARY

Time
a.m.
p.m.

FR,
PLEASE
READ
BEFORE
CONTINUING

Verify office location, if appropriate:

Edit

Item 41(1) – Accurate determination of "Number of patient visits during reporting week" is
EXTREMELY IMPORTANT! This count is to include any days the provider may have skipped
or not participated. This information may be obtained from either the office staff or from the PRF
Folio cover. Only inlcude visits to sampled provider and NOT the total number of visits to entire
practice or clinic.
Item 41(3) – If the number of Patient Record forms completed is less than 20 or greater than
40, then explain why in the NOTES section below.
Items 17e and 41(1) – If applicable, record explanation of why items 17e and 41(1) differ
significantly and any other information regarding this case which may help to understand it at a
later date.

RECORD ON CONTROL CARD

42. Final disposition for Cervical Cancer Screening Supplement (CCS)
(a) Physician/Provider Eligible for the CCS

Physician refused to participate –Go to the top of page 6.

1
2
3

Completed
Refused
Does not perform screening

(b) Other

Thank you, Dr. . . . I’ll see you then. (Go to Check Item A on the bottom of page 6.)

4

NOTES
5

Physician/Provider is ineligible for the CCS
(i.e., not a CHC provider or a physician
with a specialty of GFP, IM, OB/GYN.)
Other – Specify (e.g., unable to locate)

Edit
Page 4

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 21

Section III – NONINTERVIEW – Continued

Section I – TELEPHONE SCREENER – Continued

38. Why is provider unavailable or not in practice?

}
39a. What is the provider’s new address?

SKIP to
item 40 on
page 21

FR,
PLEASE
READ
BEFORE
CONTINUING

Number and street

FR Instruction – If you have made it to this point, it appears the physician will be
cooperative. Please remember to show the physician the Data Use Agreement and
remind them they need to keep this document for six years. If the physician or their
staff are unwilling to complete the Patient Record forms themselves and request you to
abstract the information, please remember that an Accounting Document must be
placed in each of the medical records from which information has been abstracted. This
document must also be kept for six years. If necessary, please show the physician the
IRB approval.

RECORD ON CONTROL CARD
PROVIDER’S OFFICE SCHEDULE
City, State, ZIP Code

RECORD ON CONTROL CARD

FR
INSTRUCTION

Please complete the office schedule for the week the provider is in sample.

Telephone

RECORD ON CONTROL CARD

b. Name of Field Representative

RO

PSU

Date transferred

RECORD ON CONTROL CARD

Monday
Continue
with item
40 on
page 21

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

A.M.

NOTES
P.M.

Office
No.
NOTES

Page 20

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 5

Section III – NONINTERVIEW

Section I – TELEPHONE SCREENER – Continued

FR, PLEASE READ
BEFORE CONTINUING

FR Instruction – COMPLETE QUESTIONS BELOW FOR ALL IN-SCOPE PHYSICIANS
WHO HAVE REFUSED TO PARTICIPATE.

I appreciate that you choose not to participate in the study, but I would like to ask a few
short questions about your practice so we can make sure responding physicians do not differ
from nonresponding physicians.

13a. At how many different office locations, do you
see ambulatory patients? Do not include
settings such as EDs, outpatient departments,
surgicenters, and Federal clinincs.

Number of
office locations
Number of weeks

b. In a typical year, about how many weeks do
you NOT see ambulatory patients (e.g.,
conferences, vacations, etc.)?

c. You typically see patients fewer than half
the weeks in each year. Is that correct?

d. You typically see patients all 52 weeks of
the year. Is that correct?

1
2

1
2

If > 26 weeks, ask item 13c.
If = 0, SKIP to item 13d.
If 1 to 26 weeks,
SKIP to item 13e.
Yes – SKIP to item 13e.
No – Please explain
SKIP to
item 13e

}

35. What is the reason the provider did not participate in
this study?

1
2
3

Explanations for noninterview codes 6 and 11 –

4
5

• Temporarily not practicing –Refers to duration
of 3 months or more

6

• Unavailable during reporting period –Absence
must be for duration of LESS than 3 months

9

7
8

10
11

Edit

36. Check all that apply to describe provider’s practice or
medical activities which define him/her as ineligible or
out-of-scope.

12

1
2
3

Yes
No – Please explain

4
5

6

e. During your last normal week of practice,

7

Number of
patient visits

how many patient visits did you have at all
office locations?
f. During your last normal week of practice,
how many hours of direct patient care did
you provide?

37a. At what point in the interview did the refusal/break-off

Number of
weekly hours

occur?

2

(Mark (X) one.)

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

5

Number of physicians

ambulatory patients:
(1) How many physicians are associated with
you?
1

(3) Are you a full- or part-owner, employee, or
an independent contractor?

1

2

2
3
1
2
3
4
5
6
7

(Mark (X) one.)

Multi-specialty practice
Single-specialty practice

1
2
3
4

Owner – Automatically mark "Physician or
physician group" in item 13g(4)
Employee
Contractor
Physician or physician group
HMO
Community Health Center
Medical/Academic health center
Other hospital
Other health care corporation
Other – Specify

Final outcome of screening
1
Appointment MADE or Physician unavailable during reporting period –Go to Section II, page 7
2
Inscope, but REFUSED –Complete item 13, then go to Section III, page 19
3
Out-of-Scope/Other –Go to Section III, page 19
Edit

➤ CHECK ITEM A MUST BE COMPLETED BEFORE CONTINUING
Page 6

b. By whom?

5
6

FORM NAMCS-1 (12-8-2009)

}

}

}

Federally employed
Radiology, anesthesiology or pathology
specialist
Administrator
Work in institutional setting
Work in hospital emergency
department or outpatient department
Work in industrial setting
Other – Specify

}

SKIP to
item 40
page
21

}

During telephone screening
Make sure item 13
has been completed
During induction interview
After induction but prior to assigned
reporting days
At reminder call
During assigned reporting days or
mid-week calls
At follow-up contact
Sampled provider
Sampled provider through nurse
Nurse/Secretary
Receptionist
Office manager/Administrator
Other office staff – Specify

c. What reason was given? (Verbatim)

d. Date refusal/breakoff was reported to supervisor

Month

e. Conversion attempt result
1
2
3

➤

CHECK ITEM A

6

If number of other physicians
is 0, SKIP to item 13g(3).

(2) Is this a single- or multi-specialty group
practice?

REFER TO FLASHCARD B.

3
4

g. At the office location where you see the most

(4) Who owns the practice?

1

Refused/Breakoff –SKIP to item 37a
Non-office based
SKIP to item 36
Sees no ambulatory patients
Retired
SKIP to item 40 on page 21
Deceased
Temporarily not practicing –SKIP to item 38 on page 20
Can’t locate
SKIP to item 40 on page 21
Not licensed
Moved out of U.S.A.
Other out-of-scope –SKIP to item 36
Unavailable during reporting period –SKIP to item 38 on
page 20
Moved out of PSU –SKIP to item 39a on page 20

FORM NAMCS-1 (12-8-2009)

Day

Year

}

No conversion attempt
SKIP to item 40 on
Sampled provider refused page 21
Sampled provider agreed to see
Field Representative – Complete Section II
Page 19

Section II – INDUCTION INTERVIEW

Section II – INDUCTION INTERVIEW – Continued

Before we begin, I would like to give you a little background about this study.

INSTRUCTIONS – Continued
Items 5a(1), Provider’s Primary Diagnosis for this Visit – Can be tentative or provisional or
expressed as a problem. Physician should not record "Rule Out" diagnosis (R.O.). Enter any other
diagnosis related to the visit (e.g., depression, obesity, asthma, etc.) in items 5a(2) and 5a(3).
Items 5b, Chronic Disease Checklist – Mark all chronic diseases that the patient has, regardless
of entry in item 5a. This item supplements the diagnoses reported in item 5a. If none of the conditions
listed apply, then mark "None of the above."
Item 6, Vital Signs – When possible, record specific values for the 4 vital signs. For height and
weight, enter the value on the line next to the type or measurement system used. If height was not
measured at this visit and patient is 21 years of age or over, enter the most recent height recorded.
Item 8, Health Education – Mark all services ordered or provided at this visit.
Item 9, Non-Medication Treatment – Mark and/or list all non-medical treatment including surgical
or non-surgical procedures ordered or provided at this visit.
Item 10, List medication/immunization names – Record up to 8 medications that were ordered,
supplied, administered or told to continue at the visit. Include Rx and OTC medications, immunizations,
allergy shots, anesthetics, chemotherapy, and dietary supplements. Use SPECIFIC BRAND OR
GENERIC DRUG NAMES as entered on prescription or medical records. Do NOT enter broad drug
classes such as "pain medication." Record if the medication/immunization was new or continued.
Item 13, Time Spent with Provider – Best estimate of time spent in face-to-face contact with the
patient and the sampled provider. The answer may be zero (0), if the patient was attended entirely by a
registered nurse or technician and did not see the sampled physician/CHC provider.

Systematic information about the characteristics and problems of the people who consult providers
in their offices is essential for medical researchers, educators, and others who are concerned with
medical education, manpower needs, and the changing nature of health care delivery.
In response to the demand for this information, the Centers for Disease Control and Prevention, in
close consultation with representatives of the medical profession, developed the National
Ambulatory Medical Care Survey.
Your part in the study is very simple, carefully designed, and should not take much of your time. It
consists of your participation during a specified 7-day period. During that time, you would supply a
minimal amount of information about patients you see.
Now, before we get to the actual procedures, I have some questions to ask you about your practice.
The answers you give will be used only for classification and analysis. Of course, ALL information you
provide for this study will be held in strict confidence.

14a. Overall, at how many office locations, do you see

Number of locations

ambulatory patients? Do not include settings such
as EDs, outpatient departments, surgicenters, and
Federal clinics.

b. In a typical year, about how many weeks do you
NOT see any ambulatory patients (e.g.,

Number of weeks
If > 26 weeks ask item 14c.
If = 0, SKIP to item 14d.
If 1 to 26 weeks,
SKIP to item 15a.

conferences, vacations, etc.)?

c. You typically see patients fewer than half the weeks
in each year. Is that correct?

1
2

Yes – SKIP to item 15a
No – Please explain

Item 14, Laboratory Test Results – If folio B will be used, please make sure provider is aware of
items on back of PRF, and completes information about tests drawn within last 12 months.
(3) Explain to the provider, where appropriate, that the receptionist, nurse, or assistant can list patients on
the Patient Visit Worksheet as they enter the office. They may also complete items 1–4 on the Patient
Record form.
(4) Instruct provider to enter number of patients seen and number of PRF’s completed on front of folio – at
the end of each day.

d. You typically see patients all 52 weeks of the year.
Is that correct?

1
2

}

SKIP to
item 15a

Yes
No – Please explain

15a. This study will be concerned with the AMBULATORY
patients you will see in your office(s) during the week
of Monday,

34a. CLOSING STATEMENT
Thank you for your time and cooperation Dr. . . . I will call you on

_______________ through Sunday,_______________.

Monday,_____________________ to see if (everything is all right/your plans have changed).

Are you likely to see any ambulatory patients in your
office(s) during that week?
(For allergists, family practitioners, etc. – if routine
care such as allergy shots, blood pressure checks,
and so forth will be provided by staff in physician’s
absence, mark "Yes.")

If you have any questions (Hand doctor your business card) please feel free to call me. My
telephone number is also written in the folio.

FR INSTRUCTIONS

If applicable, complete Sections III through V before returning
completed materials to office.

Yes –SKIP to item 16a on page 8
No

(If appropriate, read item 15c below and leave forms with physician. Otherwise, SKIP to item 16a on page 8.)

c. Since it’s very important that we include any ambulatory patients that you might see in your

Thank you for your time and cooperation Dr. . . . The information you provided will
improve the accuracy of the NAMCS in describing office-based patient care in the
United States.

Page 18

2

b. Why is that? Record verbatim.

34b. CLOSING STATEMENT

FR INSTRUCTIONS

1

office during that week, I’ll leave forms with you – just in case your plans change. I’ll check back
with your office just before (Starting date) to make sure, and if necessary I can explain them in
detail then.
Give the doctor the folio and enter the folio number on page 17. Then continue with item 16a on page 8.

Complete Sections III through IV before returning completed
materials to office.

FR, PLEASE READ
BEFORE CONTINUING
FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

FR Instruction – Even if the physician is not available during the reporting week, continue
with item 16a on page 8.
Page 7

Section II – INDUCTION INTERVIEW – Continued

Section II – INDUCTION INTERVIEW – Continued

16a. At what office

16b. Give FLASHCARD A (p. 15 Flashcard Booklet) and ask Looking at this

START WITH NUMBER

location(s) will you see
ambulatory patients
during your practice’s
7-day reporting period
Monday,
through Sunday,
__________________ ?

list, choose ALL of the type(s) of settings that describe each
location where you work. For each location mark all setting types that
apply. For each location, also mark the appropriate "scope" status. If any
even numbered settings are marked, then mark location as out-of-scope.

Is this/that clinic in an institutional setting (#8), in an
industrial outpatient facility (#10), or operated by the Federal
Government (#12)? (If yes – Mark out-of-scope.)

3

PROBE: Are there any
other office locations at
which you will see
ambulatory patients
during that 7-day
reporting period?

If FLASHCARD number 11 (family planning clinic) is marked, ask –
Is this/that clinic operated by the Federal Government (#12)?
(If yes – Mark out-of-scope.)

5

If FLASHCARD number 3 (free-standing clinic/urgicenter) is
marked, ask –

If in doubt about any (clinic/facility/institution), PROBE –
(1) Is this/that (clinic/facility/institution) part of a hospital
emergency department or an outpatient department (#2, #4)?
(If yes – Mark out-of-scope.)
(2) Is this/that (clinic/facility/institution) operated by the
Federal Government (#12)? (If yes – Mark out-of-scope.)

NOTE –
NON-PARTICIPATING
PHYSICIANS: If refusal
(Final=3) or unavailable
(Final=4), record locations
where ambulatory patients
are normally seen.
Office
No.

Office locations
(Enter street address)

1
2
3
4

RECORD ON CONTROL CARD
RECORD ON CONTROL CARD
RECORD ON CONTROL CARD
RECORD ON CONTROL CARD

Edit

Mark (X)

Circle
FLASHCARD number

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

6
6
6
6

7
7
7
7

8
8
8
8

9
9
9
9

10
10
10
10

Inscope

11
11
11
11

12
12
12
12

13
13
13
13

14
14
14
14

15
15
15
15

Out-ofscope

1

2

1

2

1

2

1

2

To determine the Start With (SW) number read down
the "If Take Every Number is" column and find the
Take Every Number. The number to the right is the
Start With Number. Transcribe this number onto line at
the right, and to the front of the folio, and to the Patient
Visit Worksheet if it is used.

If the Take
Every Number is:

Then the Start
With Number is:

1
2
4
Start With Number

10
15
20
25
30
Office number

Edit

Folio Number

OFFICE USE ONLY
Number of PRFs completed

1
2
3
4
Additional folio
for Office #

FLASHCARD A
(1) Private solo or group practice
(3) Freestanding clinic/urgicenter (not part of
a hospital outpatient department)
(5) Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or ‘look alike’ clinics)
(7) Mental health center
(9) Non-federal Government clinic (e.g., state,
county, city, maternal and child health,
etc.)
(11) Family planning clinic (including Planned
Parenthood)
(13) Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)
(15) Faculty Practice Plan

(2) Hospital emergency department

INSTRUCTIONS

(4) Hospital outpatient department

GIVE THE PHYSICIAN A FOLIO AND A COPY OF THE SAMPLE PATIENT RECORD FORM (NAMCS-73),
AND EXPLAIN HOW TO COMPLETE THE FORMS.

(6) Ambulatory surgicenter

Cover the following points —

(8) Institutional setting (school infirmary,
nursing home, prison)

(1) Who to list/who not to list on the Patient Visit Worksheet found in the back of the NAMCS-26

(10) Industrial outpatient facility
(12) Federal Government operated clinic
(e.g., VA, military, etc.)
(14) Laser vision surgery

16c. Are there other office locations where you NORMALLY would
see patients, even though you will not see any during your 7-day
reporting period? Do not include settings such as EDs,
outpatient departments, surgicenters, and Federal clinics.

CHECK ITEM B

1
2

• INCLUDE patients the physician doesn’t see but who receive care from an assistant, nurse, nurse
practitioner, physician assistant, etc.
• EXCLUDE patients who do not seek care or services (e.g., they come to pay a bill or leave a specimen).
• EXCLUDE telephone contacts with patients.
(2) Show doctor instruction card in folio pocket and go over Patient Record item by item, paying particular
attention to —

1
2

Yes – SKIP to item 16d
No – SKIP to Check Item B

d. Of these locations where you will not be seeing patients during
your 7-day reporting period, how many total office visits did
you have during your last week of practice at these locations?

• List every ambulatory patient visit to all in-scope locations during the reporting period.

Number of visits

All locations listed in 16a are out-of-scope – Read CLOSING STATEMENT below
All/Some locations listed in 16a are in-scope – Go to item 17a

Item 2, Injury/Poisoning/Adverse Effect – If any part of this visit was related to an injury or
poisoning or adverse effect of medical or surgical care or an adverse effect of medicinal drug, then mark
the appropriate box. If this visit was not related to any of these, then mark the last option, "None of the
above."
Item 3, Reason for Visit – To be recorded in patient’s own words. We want the patient’s own
complaint here, not the physician’s diagnosis. If the patient has no complaint, the physician should enter
the reason for the visit.

CLOSING
Thank you, Dr. . . ., your practice is not within the scope of this study.
STATEMENT We appreciate your time and interest. (Terminate interview and complete Sections III and IV on pages 19–21.)
Page 8

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 17

Section II – INDUCTION INTERVIEW – Continued

Section II – INDUCTION INTERVIEW – Continued

33b. Who will be helping you at each location? (Below enter the location and person’s name and position.)
NOTE: Keep the location numbers the same as the office numbers in item 16a.
Location
Office
Name
(Enter street name)
No.

Ask item 17a ONCE to obtain total for ALL in-scope locations.

17a. During the week of Monday, ____________ through Sunday, ___________ How many days

Position

1

RECORD ON CONTROL CARD

2

RECORD ON CONTROL CARD

3

RECORD ON CONTROL CARD

4

RECORD ON CONTROL CARD

do you expect to see any ambulatory patients? (Only include days at in-scope locations.)
NOTE – NON-PARTICIPATING PHYSICIANS: If
refusal (Final=3) or unavailable (Final=4), enter the number of
days in a normal week.

Edit

Estimated Number
of Days

Enter street name or town of in-scope location(s).

FR NOTE –Explain to the physician and to anyone helping the physician that you would like to review
some of the questions found on the Patient Record form. Go to page 17.
Visit Sampling
To select a sample of patient visits, the physician’s office will need to know where to start sampling (Start With) and how
to select subsequent patient visits (Take Every).
To determine Take Every (TE) and Start With (SW) numbers follow these instructions. Read down the "Estimated visits
for week" column to the line that corresponds to the total entry in ITEM 17e. Then, read across the "Days physician will
see patients that week" line to the column that corresponds to the entry in ITEM 17a. Circle the appropriate number. This
number is the physician’s Take Every number for all office locations. Then transcribe this number below, and onto the front
of the folio, and to the Patient Visit Worksheet if it is used.

Office location No.

NOTE: Keep the location numbers the same as the office numbers in item 16a.

RECORD ON CONTROL CARD

#1

#2

#3

#4

_____

_____

_____

_____

b. During your last normal week of practice,
approximately how many office visit encounters
did you have at each office location?
NOTE: If physician is in group practice, only
include the visits to sampled physician.

Edit

Number
of visits

TAKE EVERY NUMBER
Days physician will see patients that week
Estimated Visits for Week

c. During the week of Monday, ____________ through

1

2

3

4

5

6

7

0–12 . . . . . . . . . . . . . . . . . . . . . . .

1

1

1

1

1

1

1

13–24 . . . . . . . . . . . . . . . . . . . . . .

2

1

1

1

1

1

1

25–39 . . . . . . . . . . . . . . . . . . . . . .

3

2

1

1

1

1

1

40–44 . . . . . . . . . . . . . . . . . . . . . .

4

2

2

1

1

1

1

45–49 . . . . . . . . . . . . . . . . . . . . . .

4

2

2

2

2

2

2

50–64 . . . . . . . . . . . . . . . . . . . . . .

5

3

2

2

2

2

2

65–74 . . . . . . . . . . . . . . . . . . . . . .

10

3

2

2

2

2

2

75–89 . . . . . . . . . . . . . . . . . . . . . .

10

4

3

2

2

2

2

90–104 . . . . . . . . . . . . . . . . . . . . .

10

4

3

3

3

3

3

105–114 . . . . . . . . . . . . . . . . . . . .

10

5

3

3

3

3

3

115–129 . . . . . . . . . . . . . . . . . . . .

10

5

4

3

3

3

3

130–134 . . . . . . . . . . . . . . . . . . . .

15

10

4

3

3

3

3

135–154 . . . . . . . . . . . . . . . . . . . .

15

10

4

4

4

4

4

155–174 . . . . . . . . . . . . . . . . . . . .

15

10

5

4

4

4

4

175–194 . . . . . . . . . . . . . . . . . . . .

15

10

5

5

5

5

5

195–209 . . . . . . . . . . . . . . . . . . . .

20

10

10

5

5

5

5

associated with other physicians in a
partnership, in a group practice, or in some
other way (at this/that in-scope location)?

210–219 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

5

5

5

b. How many physicians are associated with you

220–254 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

10

10

10

255–319 . . . . . . . . . . . . . . . . . . . .

25

15

10

10

10

10

10

320–364 . . . . . . . . . . . . . . . . . . . .

30

15

10

10

10

10

10

365+ . . . . . . . . . . . . . . . . . . . . . . .

30

30

30

30

30

30

30

Sunday ____________, do you expect to have about
the same number of visits as you saw during
your last normal week in each office taking into
account time off, holidays, and conferences?

Yes . .
No . . .

1

1

1

1

2

2

2

2

NOTE: Mark (X) response. If answer is "Yes", transcribe
the number in 17b to 17d for that office location. If answer
is "No" then ASK item 17d for that office location.

d. Approximately how many ambulatory visits do
you expect to have at this office location?

Number
of visits

_____

_____

_____

_____

e. Tally of estimated number of visits
NOTE: To obtain the total number of estimated visits,
add the estimate for each office location in 17d.

Number of visits
_____

Now, I’m going to ask about your practice at
(in-scope location).

18a. Do you have a solo practice, or are you

#1

Office Location

#2

#3

#4

Solo . . . . . . . . . . . . 1
1
1
If Solo, SKIP to item 18d.

1

Nonsolo . . . . . . . . .

2

2

2

2

(at this/that in-scope location)?
How many

c. Is this a single- or multi-specialty (group)
practice (at this/that in-scope location)?

_____

_____

_____

_____

Multi . . . . . . . . . .

1

1

1

1

Single . . . . . . . . .

2

2

2

2

Take Every Number
Page 16

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 9

Section II – INDUCTION INTERVIEW – Continued

Section II – INDUCTION INTERVIEW – Continued

18d. How many mid-level providers (i.e., nurse

practitioners, physician assistants, and
nurse midwives) are associated with you
How many
(at this/that in-scope location)?
e. Are you a full- or part-owner, employee, or an Owner . . . . . . . .
independent contractor (at this/that in-scope
Employee . . . . . .
location)? If "Owner" is marked then automatically
Contractor . . . . .
mark "Physician or physician group" in item 18f.

f. Give FLASHCARD B (p.16 Flashcard Booklet)
and ask:
Who owns the practice (at this/that in-scope
location)?

#2

#1

Office Location

#3

#4

a. What is your year of birth?
_____

_____

_____

_____

1

1

1

1

2

2

2

2

3

3

3

3

Physician or
physician group . . .
HMO . . . . . . . . .
Community Health
Center . . . . . . . .
Medical/ Academic
health center . . . .
Other hospital . . .
Other health care corp
Other . . . . . . . . .

1

1

1

2

2

2

2

2

c. Give FLASHCARD F (p.20 Flashcard Booklet) and ask:

1

3

3

3

3

4

4

4

4

4
5

5

5

5

5

6

6

6

6

7

7

7

7

}

MD
Go to item 32d
DO
Nurse practitioner
SKIP to
Physician assistant
FR INSTRUCTION
Nurse midwife
on page 15.
Other

}

Yes
No
DK

1
2
3

Yes
No
DK

1
2
3

Yes
No
DK

1
2
3

Name of specialty

Code

Name of specialty

Code

e. What is your secondary specialty?
Yes
No
DK

f. What is your primary board certification?

RECORD ON CONTROL CARD

location?

Male
Female

d. What is your primary specialty?

2

h. What is your Federal Tax ID at each office

3

6

3

19a. During your last normal week of practice,

Board certification

g. What is your secondary board certification?

how many hours of direct patient care did
you provide?

Number of
weekly hours

Board certification

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

h. What year did you graduate medical school?
Year

i. Did you graduate from a foreign medical school?

b. During your last normal week of practice,

1
2

Number of encounters
per week

about how many encounters of the
following type did you make with patients:

(3) Hospital visits

1

What is your highest medical degree?
1

1

evening or on weekends?

(2) Other home visits

b. What is your sex?

1 9

2

g. Do you see patients in the office during the

(1) Nursing home visits

32. Provider demographics –

FR INSTRUCTION

..................

Yes
No

If physician unavailable during reporting period, SKIP to item 34b on page 18.

....................

33a. During the period Monday, ________________ through

.......................

(4) Telephone consults

..................

Sunday, ________________ will ANYONE be available
to help you fill out the patient record forms for this
study (at in-scope locations)?

(5) Internet/e-mail consults . . . . . . . . . . . . . . .

electronically (Electronic billing)?

1
2
3
4

21a. Does your practice use ELECTRONIC

MEDICAL RECORD (EMR) OR ELECTRONIC
HEALTH RECORD (EHR)? (Do not include
billing records systems)?

1
2
3
4

2

Yes
No – Go to Visit Sampling on page 17

FR NOTE – Explain to the physician that
you would like to review some of the
questions found on the patient record form.

NOTES

Have provider answer ALL remaining questions for the
in-scope location/practice with the most visits.

20. Does your practice submit claims

1

Yes, all electronic
Yes, part paper and part electronic
No
Don’t know

}

Yes, all electronic
Go to item 21b
Yes, part paper and part electronic
No
Skip to item 22
Don’t know

}

b. Which year did you install your EMR/EHR
system?

Year
Page 10

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 15

Section II – INDUCTION INTERVIEW – Continued

Section II – INDUCTION INTERVIEW – Continued

21c. What is the name of your current

Item 30 should only be asked of GFP, IM, PD, OB/GYN,
physicians and all providers at community health centers.
Otherwise SKIP to item 31.

30a. Does your practice currently recommend the
Human Papillomavirus (HPV) vaccine?

EMR/EHR system?

1
2
3

1
2

4

Yes – SKIP to item 30c
No – Go to item 30b

5
6

b. Does your practice plan on recommending the
HPV vaccine?

c. Which HPV vaccine does your practice
recommend using?

1
2

1
2
3
4

d. What age group(s) does your practice
recommend patients get the HPV vaccine?
Mark (X) all that apply.

1
2
3
4
5
6

Yes – Go to item 30c
No – SKIP to item 30e

22. At your practice, are there plans for installing
a new EMR/EHR system within the next 18
months?

Gardasil (quadrivalent vaccine)
Cervarix (bivalent vaccine)
Both
Don’t know
Females 9–12 years of age
Females 13–26 years of age
Females 27 years of age and older
Males 9–12 years of age
Males 13–26 years of age
Males 27 years of age and older

practice does NOT plan on recommending
the HPV vaccine.

3

23. Does your practice have each of the

}

computerized capabilities listed below. CHECK
NO MORE THAN ONE
BOX PER ROW. Does your practice have a
computerized system for:
SKIP to item 31

1
2
4

6
7
8
9
10
11
12
13

a. Patient history & demographic information? . . . . . .
If Yes, ask – (1) Does this include patient problem lists?

Not a large proportion of recommended age group in my
practice
Concern that it encourages sexual promiscuity
Not wanting to convince parents/patients to accept vaccine
Awkwardness of conversation that HPV is sexually
transmitted
Concern about safety of the vaccine
Concern about failure of vaccine to prevent all cervical
cancer
Concern about thiomersal in vaccine
Concern about decreased efficiacy in a population that
has been exposed to HPV (i.e., sexually active)
Concern that the office schedule is too crowded to
accommodate additional visits
Insurance reimbursement issues
Up-front costs to purchase vaccine
Concern regarding the storage and administration
protocol of vaccine
Other – Specify

If Yes, ask – (1) Do they include a list of medications that the
patient is taking?
(2) Does this include a comprehensive list of the
patient’s allergies (including allergies to
medication)?
c. Orders for prescriptions? . . . . . . . . . . . . . . . . . . . . . . .

1

2
3

Yes

1

11

Yes, but
turned off
or
not used
2

1

2

1

2

Yes – Leave a NAMCS-CCS only if physician’s
speciality is GFP, IM, OB/GYN or provider works
at a community health center.
Please specify e-mail address

If Yes, ask – (1) Are warnings of drug interactions or
containdications provided?
(2) Are prescriptions sent electronically to the
pharmacy?
d. Orders for lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14
15
16

Praxis
Practice One
Sage Intergy
Other
Unknown

If Yes, ask – (1) Are orders sent electronically?
e. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No

3

Skip to 23b
3
3

Skip to 23c

Unknown

4

Skip to 23b
4
4

Skip to 23c

3

4

1

2

3

4

1

2

3

Skip to 23d

4

Skip to 23d

1

2

3

4

1

2

3

4

1

2

3

4

Go to 23d1 Skip to 23e
1

2

1

2

Go to 23e1 Skip to 23f

Skip to 23e
3
3

Skip to 23f

Skip to 23e
4
4

Skip to 23f

1

2

3

4

1

2

3

4

Viewing imaging results? . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

g. Reminders for guideline-based interventions
or screening tests? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

h. Electronic reporting to immunization registries? . . .

1

2

3

4

f.

tests are submitted electronically, who submits
them?

Is provider part of the community health center sample?
1
Yes – Ask item 32
No – SKIP to FR INSTRUCTION on page 15
2

1
2

4
5
6

FORM NAMCS-1 (12-8-2009)

13

2

24. At your practice, if orders for prescriptions or lab

No
Don’t know

12

1

3

Page 14

10

Go to 23c1 Skip to 23d

(2) Are out of range levels highlighted?

CHECK ITEM C

9

GE Centricity
Greenway
Medical
HealthPort
McKesson
NextGen

Go to 23a1 Skip to 23b

If Yes, ask – (1) Are results incorporated in EMR/EHR?

31.

8

Go to 23b1 Skip to 23c

5

Ask of all physicians/providers
Do you offer any type of cervical cancer
screening?

7

Yes
No
Maybe
Unknown

b. Clinical notes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

Mark (X) all that apply.

2
4

Give FLASHCARD E (p.19 Flashcard Booklet)
and ask:

e. Please indicate the reason(s) why your

1

Allscripts
Cerner
eClinicalWorks
Eclipsys
Epic
eMDs

FORM NAMCS-1 (12-8-2009)

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Other
Prescriptions and lab test orders
not submitted electronically
Page 11

Section II – INDUCTION INTERVIEW – Continued

25. Beginning in 2011, Medicare and Medicaid will offer
incentives to practices that have "meaningful use of
Health IT". At the reporting location, are there plans
to apply for Medicare or Medicaid incentive payments
for meaningful use of Health IT?

a. What year do you expect to apply for the
meaningful use payments?

1

Yes, we intend to apply – Go to
Question 25a

2

Uncertain whether we will apply Skip to
No, we will not apply
item 26

3
1
2
3
4

b. What incentive payment do you plan to appy for?

1
2
3

}

Section II – INDUCTION INTERVIEW – Continued
Percent of revenue from
c. Roughly, what percentage of the patient care
managed care
revenue received by this practice comes from
(these) managed care contracts?

27. Give FLASHCARD D (p.18 Flashcard Booklet) and ask:

2011
2012
After 2012
Unknown
Medicare
Medicaid
Unsure

Give FLASHCARD C (p.17 Flashcard Booklet) and ask
items 26–29 ONCE for ALL in-scope locations.
I would like to ask a few questions about your practice
revenue and contracts with managed care plans.

26a. Roughly, what percent of your patient care revenue
comes from –

Percent of patient care
revenue

(1) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(2) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(3) Private insurance?. . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

Edit

%
Percent of patient care
revenue

Roughly, what percent of your patient care revenue
comes from each of the following methods of payment?
(1) Usual, customary and reasonable fee-for-service?

%

(2) Discounted fee for service? . . . . . . . . . . . . . . . . . . .

%

(3) Capitation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Case rates (e.g., package pricing/episode
of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
%

(5) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.

28a. Are you currently accepting "new" patients into your

3

Yes
No – SKIP to item 29
Don’t know – SKIP to item 29

1

Yes

2

No

3

Don’t know

..........................

1

Yes

2

No

3

Don’t know

(2) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(3) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(4) Workers compensation?

.....................

1

Yes

2

No

3

Don’t know

(5) Self-pay? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(6) No charge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

No

3

Don’t know

practice(s) (at in-scope locations)?

1
2

b. From those "new" patients, which of the following
types of payment do you accept (at in-scope locations)?
(1) Private insurance –

%

(5) Other? –(including charity, research, CHAMPUS, VA, etc.)

(a) Capitated?

FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.

b. Roughly, how many managed care contracts does
this practice have such as HMOs, PPOs, IPAs, and
point-of-service plans?
If necessary read: Managed care includes any type of
group health plan using financial
incentives or specific controls to
encourage utilization of specific
providers associated with the plan.

1
2
3
4

None – SKIP to item 27
Less than 3
3 to 10
More than 10

..............................

(b) Non-capitated?

29a. Roughly, what percent of your daily visits are
same day appointments?

FR NOTE – Include Medicare managed care and
Medicaid managed care, but not
traditional Medicare and Medicaid.
Include any private insurance managed
care plans. Be sure the response is about
contracts and not patients.

%

b. Does your practice set time aside for same
1

Yes

c. On average, about how long does it take to get

1

an appointment for a routine medical exam?

2

Within 1 week
1–2 weeks
3–4 weeks
1–2 months
3 or more months
Do not provide routine
medical exams
Don’t know

day appointments?

3

Include all the different plans an
insurance provider may have and for
which the physician has a contract. For
example, the physician may have a
contract for each of the plans Aetna may
offer: a PPO, IPA, and point-of-service
plan. This would equal 3 contracts, not 1
contract. It may be necessary to obtain
information from the billing office of the
practice.
Page 12

4
5
6
7

2

NOTES

FORM NAMCS-1 (12-8-2009)

FORM NAMCS-1 (12-8-2009)

Page 13