Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version

Confidential Patient Check List

Page X of Y

[FILL PROVIDER ID]

PROVIDER NAME:

Instructions

Thank you for taking the time to provide this medical records information. We realize your time is valuable and limited. 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.

Step 1: Please Locate Medical 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.

• Date(s) of service

• Services provided

• Type of personnel who delivered services

• Diagnoses/conditions

• Names, specialties and telephone numbers (if available) for practitioners who provided service to the patient in the hospital but billed separately

Step 2: Please Record Outcome on the Confidential Patient Checklist: Please 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 via Fax or Mail: Please assemble the information for all patients in the Confidential Patient Check List and fax or mail it to us, using the Fax or Mail Return Form. Please include the completed Confidential Patient List, with the appropriate box checked for each patient, 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 records 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 Patient Check List

Please use the check list below as a way to record the outcome of locating each patient record in your files, and include it when faxing or mailing your materials. If you choose to provide the medical records 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.

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