Attachment 16 -- HC MEPS Record Keeper

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Doctors

Hospitals

Pharmacies

Other

Name _________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

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______________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

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______________________________________

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______________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

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______________________________________

______________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

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______________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Name _________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

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Phone ________________________________

Phone ________________________________

Phone ________________________________

Phone ________________________________

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3.6875 panel width
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MEPS
Medical Expenditure Panel Survey

Your Health Care

Record
Keeper
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

28327.1109.85772501

OMB #0935-0118
10-450

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3.625 panel width
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3.625 panel width
3_5/8

3.6562 panel width
3_21/32

3.6875 panel width
3_11/16

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Change/Payment_______________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Change/Payment_______________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Change/Payment_______________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

On the back of the

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

record keeper there

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

is space to record

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Change/Payment_______________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

providers’ contact

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Date_ _________________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

Provider_______________________________

information.

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Reason________________________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Charge/Payment_ ______________________

Change/Payment_______________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Prescriptions___________________________

Instructions
You may use this record
keeper to help prepare for
your MEPS interviews.
Each time you receive health
care, record the following
information:
• household member’s name
• date of the visit or phone call
• name of health care provider
• reason for the visit or phone call
• charge and payment information
• any medications prescribed

your health care