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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.   A data collection specialist will be calling you soon to collect this information over the telephone.  If you would like to contact us directly, please call [fill appropriate 800 number].
The patient(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.
Please complete the following steps to provide us with the records we need.
Step 1:  Please Locate Medical Billing Records for Each Patient in Your Records:  For each patient included in the Confidential Patient Checklist, please locate the following information on all services each patient received between January 1, 2009 and December 31, 2009.  Please be sure to include all charges and payment or adjustment activity that has taken place since the time of discharge.    
    • Date(s) of service
    • Services provided
    • Type of personnel who delivered services
    • Diagnoses/conditions
    • Payments and who made them (private insurance, Medicare, Medicaid, out-of-pocket, etc.)
    • Charges for each service provided and total charges


Step 2:  Please Record Outcome on the Confidential Patient Checklist:  You can use the Confidential Patient Check List as a reference tool to record whether you were able to locate the records for each patient on the list. You can indicate whether you were able to locate the 2009 patient records, if you were able to locate the patient but there were no 2009 records, or if the individual is not a patient, by checking the appropriate box next to the patient in the Confidential Patient Checklist.  

Step 3: Please Provide Information to Data Collection Specialist via Telephone:  We will be calling you shortly to collect the information.  Should you prefer, you can fax or mail the information using the attached Fax or Mail Return Form.  If returning records by fax or mail, please include the completed Confidential Patient List, with the appropriate box checked for each patient, in the package.






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[FILL PROVIDER ID]
PROVIDER NAME: 
Confidential Patient Check List
If you provide the medical billing information over the telephone, you may use this list as a reference tool for recording the outcome of locating each patient record in your files.  If you choose to mail or fax the medical billing information for each patient, please include this checklist form with your materials.
  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 PATIENT:
Patient Name
Date of Birth
Gender
2009 Patient 
Records Located
Found Patient, 
No 2009 Records
Is Not 
A Patient






1.  [FILL NAME]
[FILL DOB]
[FILL  M or F]
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

2.  [FILL NAME]
[FILL DOB]
[FILL  M or F]


