Att L AS PRF

Attachment L

OMB No. 0920-xxxx Exp. Date

Ambulatory Surgery Patient Record form

Ambulatory Care Pretest, National Hospital Care Survey

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).

Patient’s name: ________________________________________________________

Patient’s address: ______________________________________________________ Street

____________________________ City _______ State

Patient’s Social Security number _____________________

Patient’s Control number ____________________________

Medicare health insurance benefit/claim number ___________________________

National Provider Identifier (NPI) - Attending _______________________________

National Provider Identifier (NPI) - Operating _______________________________