Attachment 3 -- HC About MEPS-MPC Permission Form

About the MEPS Authorization Form

Medical Expenditure Panel Survey

Logo:

MEPS

Medical Expenditure Panel Survey

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

If you have questions about how to complete these forms, please call Alex Scott, a survey representative, at this toll-free number: 1-800-945-MEPS (6377)

Questions & Answers About Authorization Forms

Medical Expenditure Panel Survey

Q. I’ve already given you this information. Why do you need to contact my health care providers?

A. We contact health care providers for valuable additional information about your health care services and prescribed medicines. They are also asked about the charges for their services and whether those charges were paid for out of pocket, by insurance, or by another source. Their answers supplement information you have given and make MEPS data more complete and more useful to researchers.

Q. How will you contact my doctor, hospital, or pharmacy?

A. Most providers will be contacted by telephone. Usually, a clerk in your doctor’s office or hospital will be able to provide the information we request. Pharmacies often have a simpler approach — they print out a computerized summary of medications prescribed for you.

As part of your household’s participation in this important survey, MEPS is asking for authorization to contact your family’s health care providers to supplement the information given to us during the in-person interviews. In order to contact the medical providers and pharmacies used by members of your house hold, we need to have the enclosed authorization forms signed.

The information we receive from these providers will allow researchers to better understand how your family’s health care needs are being met and paid for. For example, we will obtain additional information about services received from medical providers, prescriptions filled or refilled from pharmacies, and sources that helped pay for your health care.

Any medical provider or pharmacy has the right to refuse to participate, just as you do. However, our experience has been that most doctors, hospitals, and pharmacies are very willing to provide this information if they know that the patient has signed an authorization form.

Thank you for your support of this important research effort.

Sincerely,

[Signature]

Carolyn Clancy, M.D.

Director

Agency for Healthcare Research and Quality

[Signature]

Edward J. Sondik, Ph.D.

Director

National Center for Health Statistics

Centers for Disease Control and Prevention

B. I am voluntarily participating in the Medical Expenditure Panel Survey (MEPS), a study of health care use and expenses being conducted by the U.S. Department of Health and Human Services. I authorize and request that you provide the U.S. Department of Health and Human Services and its contractors with medical and financial information they request about all health services provided to me during the period January 1, 2009 to December 31, 2010. This authorization form covers any care I received at your facility during this period, including treatment for mental health, alcohol, drug abuse, STD, HIV, or AIDS. It also covers care I received during this period from any medical provider associated with your facility or who provided care to me in your facility.

I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA)(1) prohibits you from releasing my information without my authorization. This form (or a photocopy of this form) gives you my authorization. I have signed this form voluntarily, with the understanding that my decision to sign or not to sign the form will have no effect on my eligibility for treatment, payment, enrollment, or eligibility for any benefits to which I am entitled.

I understand that the Department of Health and Human Services and its contractors will use this information to supplement the information I have already given for MEPS research on health care use and expenditures. I also understand that once my information is released to the study, it is no longer covered by HIPAA but is covered by the Public Health Service Act, and will be kept private to the extent permitted by law. That law prohibits the release of information that would identify me permission or that of my medical providers.

I authorize the study to use information I have given in the survey to help you identify my records. I also understand that I can revoke this authorization at any time by contacting a study representative in writing or by telephone, but that my revocation will not affect disclosures already made by a provider relying on my authorization. Otherwise, this authorization expires 30 months from the date of signature.

OMB #0935-0118

PUBLICATION: 09-401

25540.1008.85770501

DHHS Logo or my medical providers outside the sponsoring agency and its contractors without my