National Ambulatory Medical Care Survey 2013 Panel

Attachment A

OMB No. 0920-0234: Expiration date 12/31/2014

NOTICE - Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).
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).

1. Physican’s address:

NAMCS-1A

FORM
(7-25-2012)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

ACTING AS DATA COLLECTION AGENT FOR THE

NATIONAL CENTER FOR HEALTH STATISTICS

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL AMBULATORY
MEDICAL CARE SURVEY
2013 PANEL
2. Physician’s telephone and FAX numbers (Area code and number)
Office
1

Telephone

Office Telephone
2
FAX

FAX

3. Progress Record
Activity

Date Completed

FR Code

Notes

Telephone Screener
Induction Interview
Patient Record Forms Completed
Final Disposition and Summary
Section I – TELEPHONE SCREENER

4. Record of telephone calls
Call

1
2
3
4
5
6
7

Date

Time

Results

If interview is with a CHC provider, start with Section II on page 5, but remember
to complete the office hours on page 4.

INSTRUCTION

5. Introduction

PY

The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS)
is conducting the National Ambulatory Medical Care Survey (NAMCS). This annual study, which
has been in the field since 1973, collects information about the large portion of ambulatory care
provided by physicians and mid-level providers throughout the United States. Research utilizing
the NAMCS helps to inform physicians, health care researchers, and policy makers about the
changing characteristics of ambulatory health care in this country. The information that will be
requested includes data about the patient visit (e.g., demographics, diagnoses, services, and
treatments), physician practice characteristics (e.g., practice type), and the use of electronic
medical records.

O

N

to
ol

A

L

co
lle
ct
io
n

C

O

Many organizations and leaders in the health care community, including those providing the
enclosed letter of endorsement, have expressed their support and join me in urging your
participation in this meaningful study. You will be asked to complete a short electronic
questionnaire on a sample of about 30 patient encounters during a randomly assigned one-week
reporting period. Additionally, there is a short interview (approximately 35 minutes) with you
about the nature of your practice. You may be asked to complete a short paper supplement, insert "and Federal
which would take about an additional 20 minutes. We intend to conduct additional health care
tax ID" after NPI
research by linking your National Provider Identifier (NPI) collected in this study to health
care-related data such as Medicare records. Participation is voluntary, and you or your staff may
refuse to answer any question or may stop participating at any time without penalty or loss of
benefits.

da
ta

The following are some key points about the survey:

a

TI

• Data collection for the NAMCS is authorized by Section 306 of the Public Health Service Act
(Title 42, U.S. Code, 242k).

as

us
ed

R

M

A

• All information collected will be held in the strictest confidence according to Section 308(d) of
the Public Health Service Act (42, U.S. Code, 242m(d)) and the Confidential Information
Protection and Statistical Efficiency Act (Title 5 of PL 107-347). This information will be used
for statistical purposes only. No patient names, social security numbers, or addresses are
collected.

be

N
ot
to

FO

• This study conforms to the Privacy Rule as mandated by HIPAA, because disclosure of
patient data is permitted for public health purposes, the NCHS Research Ethics Review Board
has approved NAMCS.

IN

• U.S. Census Bureau employees, who administer the study, have taken an oath to abide by
Title 13, U.S. Code, Section 9, which requires them to keep all information about your practice
and patients confidential.
A representative of the Census Bureau, acting as our agent, will be calling you to schedule an
appointment regarding the details of your participation. If you have any questions regarding your
participation, please call a NAMCS representative at 1–800–392–2862. Additional information on
the survey may be obtained by visiting the NAMCS participant Web site at
www.cdc.gov/namcs/ahcd/namcs_participant.htm.
You may have questions about your rights as a participant in the research study. If so, please
call the Research Ethics Review Board at the National Center for Health Statics, toll-free at
1–800–223–8118. Please leave a brief message with your name and phone number. Say that
you are calling about Protocol #2010-02. Your call will be returned as soon as possible.
We greatly appreciate your cooperation.
Sincerely,
Edward J. Sondik, PH. D.,
Director

Page 2

FORM NAMCS-1A (7-25-2012)

Section I – TELEPHONE SCREENER – Continued

6. Specialty
a. Your specialty is _______________________________ ,
1

is that right?

2

Yes – SKIP to item 6c
No

Edit

b. What is your specialty (including general
practice)?
(Name of specialty)
Code
Refer to the NAMCS-21, pages 3 and 4 for codes.

c. What is your ethnicity?

1
2

d. What is your race?
Enter (X) one or more.

1
2
3
4
5

7.

Which of the following categories best
describes your professional activity –
patient care, research, teaching,
administration, or something else?

1
2
3
4
5

8a. Do you directly care for any ambulatory
patients in your work?

1
2
3

b. PROBE: We include as ambulatory patients,
any patients coming to see you for personal
health services who are not currently on
the premises. Does your work include any
such individuals?

c. Do you work as an employee or a contractor
in a federally operated patient care setting
or in a hospital emergency or outpatient
department?

d. In addition to working in a federally
operated patient care setting, hospital
emergency or outpatient department, do
you also see any ambulatory patients in
another setting?

FORM NAMCS-1A (7-25-2012)

1
2

1
2

1
2

Edit

Hispanic or Latino
Not Hispanic or Latino
White
Black/African-American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaska Native
Patient care
Research
Teaching
Administration
Something else – Specify

Yes – SKIP to item 8c
No – does not give direct care [8b PROBE]
No longer in practice – SKIP to item 10 on page 4
Yes, cares for ambulatory patients
No, does not give direct care –Determine
reason, then read item 10 on page 4
Yes
No – SKIP to item 9a on page 4
Yes
No – SKIP to item 10 on page 4

If "Yes" to item 8d, all of the following questions
are concerned with the private patients.

Page 3

Section I – TELEPHONE SCREENER – Continued

9a. We have your address as (Read address shown

1

in item 1). Is that the correct address for your
office?

b. What is the (correct) address and telephone

2

Yes – SKIP to item 12
No, incorrect address – Ask item 9b

Number and street

number of your office?
City

State

ZIP Code

Telephone (Area code and number)

10. Has the physician moved out of the
United States?

1
2

11. Is the physician retired or deceased?

1
2

Yes – SKIP to CHECK ITEM A on page 7
No

}

SKIP to
item 12

Yes – SKIP to CHECK ITEM A on page 7
No

12. Thank you, Dr. . . ., but I believe that since you do not (see any ambulatory
patients/practice any longer), our questions would not be appropriate for you. I
appreciate your time and interest. (Go to Check Item A on page 7.)
PROVIDER’S OFFICE SCHEDULE

INSTRUCTION
Monday

Please complete the office schedule for the week the provider is in sample.

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

A.M.

P.M.

Office
No.
NOTES

Page 4

FORM NAMCS-1A (7-25-2012)

Section II – INDUCTION INTERVIEW
Before we begin, I would like to give you a little background about this study.
Systematic information about the characteristics and problems of the people who consult providers
in their offices is essential for medical researchers, educators, and others who are concerned with
medical education, manpower needs, and the changing nature of health care delivery.
In response to the demand for this information, the Centers for Disease Control and Prevention, in
close consultation with representatives of the medical profession, developed the National
Ambulatory Medical Care Survey.
Your part in the study is very simple, carefully designed, and should not take much of your time. It
consists of your participation during a specified 7-day period. During that time, you would supply a
minimal amount of information about patients you see.
Before COLLECTING any patient data, I have some questions to ask you about your practice. The
answers you give will be used only for classification and analysis. Of course, ALL informatin you
provide for this study will be held in strict confidence.
Number of locations

13a. Overall, at how many office locations do you see
ambulatory patients? Do not include settings such
as EDs, outpatient departments, surgicenters, and
Federal clinics.

Number of weeks

b. In a typical year, about how many weeks do you
NOT see any ambulatory patients (e.g.,

If > 26 weeks ask item 13c.
If = 0, SKIP to item 13d.
If 1 to 26 weeks,
SKIP to item 14a.

conferences, vacations, etc.)?

c. You typically see patients fewer than half the weeks
in each year. Is that correct?

d. You typically see patients all 52 weeks of the year.
Is that correct?

1
2

1
2

Yes – SKIP to item 14a
No – Please explain

}

SKIP to
item 14a

Yes
No – Please explain

14a. This study will be concerned with the AMBULATORY
patients you will see in your office(s) during the week
of Monday,
_______________ through Sunday,_______________.
Are you likely to see any ambulatory patients in your
office(s) during that week?
(For allergists, family practitioners, etc. – if routine
care such as allergy shots, blood pressure checks,
and so forth will be provided by staff in physician’s
absence, enter "Yes.")

1
2

Yes –SKIP to item 15a on page 6
No

b. Why is that? Record verbatim.
(If appropriate, read item 15c below and leave forms with physician. Otherwise, SKIP to item 16a on page 8.)
(If appropriate, read item 14c below. Otherwise, SKIP to item 16a on page 7.)

c. Since it’s very important that we include any ambulatory patients that you might see in your
office during that week, I’ll check back with your office just before (Starting date) to make sure your
plans have not changed.
PLEASE READ
BEFORE CONTINUING
FORM NAMCS-1A (7-25-2012)

Instruction – Even though the physician/provider is not available during the reporting
week, continue with item 15a on page 6.
Page 5

Section II – INDUCTION INTERVIEW – Continued

15a. At what office location(s) will you
see ambulatory patients during
your practice’s 7-day reporting
period Monday,
through Sunday, __________________ ?
(1) Are there any other office
locations at which you will see
ambulatory patients during that
7-day reporting period?

(2) What is the street address?

(3) In what city is this office
located?

15b. Looking at FLASHCARD B below, choose ALL of the type(s)
of settings that describe each location where you
work. For each location enter all setting types that apply. For
each location, also enter the appropriate "scope" status. If any
even numbered settings are entered, then enter location as
out-of-scope.
If FLASHCARD number 3 (free-standing clinic/urgicenter) is
entered, ask –
Is this/that clinic in an institutional setting (#8), in an
industrial outpatient facility (#10), or operated by the
Federal Government (#12)? (If yes – Enter out-of-scope.)
If FLASHCARD number 11 (family planning clinic) is entered, ask –
If in doubt about any clinic/facility/institution, PROBE –
(1) Is this/that (clinic/facility/institution) part of a
hospital emergency department or an outpatient
department (#2, #4)? (If yes – Enter out-of-scope)
1
2

(4) In what state is this office?

Yes
No

(2) Is this/that (clinic/facility/institution) operated by
the Federal Government (#12)? If yes – Enter
out-of-scope)

(5) What is the Zip code for this
office?

1
2

Yes
No

Edit

FLASHCARD B
(1) Private solo or group practice
(3) Freestanding clinic/urgicenter (not part of
a hospital outpatient department)
(5) Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or ‘look alike’ clinics)
(7) Mental health center
(9) Non-federal Government clinic (e.g., state,
county, city, maternal and child health,
etc.)
(11) Family planning clinic (including Planned
Parenthood)
(13) Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)
(15) Faculty practice plan
Office
No.

Office locations
(Enter street address)

(2) Hospital emergency department
(4) Hospital outpatient department
(6) Ambulatory surgicenter
(8) Institutional setting (school infirmary,
nursing home, prison)
(10) Industrial outpatient facility
(12) Federal Government operated clinic
(e.g., VA, military, etc.)
(14) Laser vision surgery

Mark (X)

Circle
FLASHCARD number

1
1 2 3 4 5 6 7 8 9 10
2
1 2 3 4 5 6 7 8 9 10
3
1 2 3 4 5 6 7 8 9 10
4
1 2 3 4 5 6 7 8 9 10
15c. Are there other office locations where you NORMALLY would

Inscope

11
11
11
11

see patients, even though you will not see any during your 7-day
reporting period? Do not include settings such as EDs,
outpatient departments, surgicenters, and Federal clinics.

12
12
12
12
1

13
13
13
13

14
14
14
14

15
15
15
15

Out-ofscope

1

2

1

2

1

2

1

2

Yes – SKIP to item 15d

2

d. Of these locations where you will not be seeing patients during
your 7-day reporting period, how many total office visits did
you have during your last week of practice at these locations?
Page 6

Number of visits
FORM NAMCS-1A (7-25-2012)

Section II – INDUCTION INTERVIEW – Continued
CHECK ITEM A

1
2

All locations listed in 15a are out-of-scope – Read CLOSING STATEMENT below
All/Some locations listed in 15a are in-scope – Go to item 16a

CLOSING
Thank you, Dr. . . ., your practice is not within the scope of this study.
STATEMENT We appreciate your time and interest. (Terminate interview and complete Sections III and IV on pages 20–22.)
Ask item 16a ONCE to obtain total for ALL in-scope locations.

16a. During the week of Monday, ____________ through Sunday, ___________ how many days do
you expect to see any ambulatory patients? (Only include days at in-scope locations.)
NOTE – NON-PARTICIPATING PHYSICIANS: If
refusal (Final=3) or unavailable (Final=4), enter the number of
days in a normal week.

Edit

Estimated Number
of Days

Enter street name or town of in-scope location(s).
Office location No.

NOTE: Keep the location numbers the same as the office numbers in item 15a.
#1

#2

#3

#4

_____

_____

_____

_____

b. During your last normal week of practice,
approximately how many office visit encounters
did you have at each office location?
NOTE: If physician is in group practice, only
include the visits to sampled physician.

Edit

Number
of visits

c. During the week of Monday, ____________ through
Sunday ____________, do you expect to have about
the same number of visits as you saw during
your last normal week in each office taking into
account time off, holidays, and conferences?

Yes . .
No . . .

1

1

1

1

2

2

2

2

NOTE: Enter (X) response. If answer is "Yes", transcribe
the number in 16b to 16d for that office location. If answer
is "No" then ASK item 16d for that office location.

d. Approximately how many ambulatory visits do
you expect to have at this office location?

e. Tally of estimated number of visits
NOTE: To obtain the total number of estimated visits,
add the estimate for each office location in 16d.

Number
of visits

_____

_____

_____

_____

#3

#4

Number of visits
_____

Answer 17a–21a for the in-scope location/practice with the most visits.
Now, I’m going to ask about your practice at
(in-scope location).

17a. Do you have a solo practice, or are you
associated with other physicians in a
partnership, in a group practice, or in some
other way (at this/that in-scope location)?

#1

Office Location

#2

Solo . . . . . . . . . . . . 1
1
1
If Solo, SKIP to item 17d.

1

Nonsolo . . . . . . . . .

2

2

2

2

b. How many physicians are associated with you
(at this/that in-scope location)?

c. Is this a single- or multi-specialty (group)
practice (at this/that in-scope location)?

FORM NAMCS-1A (7-25-2012)

How many

_____

_____

_____

_____

Multi . . . . . . . . .

1

1

1

1

Single . . . . . . . .

2

2

2

2

Page 7

Section II – INDUCTION INTERVIEW – Continued

17d. How many mid-level providers (i.e., nurse

e.

practitioners, physician assistants, and
nurse midwives) are associated with you
How many
(at this/that in-scope location)?
Are you a full- or part-owner, employee, or an Owner . . . . . . . . .
independent contractor (at this/that in-scope
Employee . . . . . . .
location)? If "Owner" is marked then automatically
Contractor . . . . . . .
mark "Physician or physician group" in item 17f.

f. Give FLASHCARD A (p.15 Flashcard Booklet)
and ask:
Who owns the practice (at this/that in-scope
location)?

Insurance company, health plan, or HMO

#2

#3

#4

_____

_____

_____

1

1

1

1

2

2

2

2

3

3

3

3

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

6

6

6

6

7

7

7

7

#1

Office Location

Physician or
physician group . . . .
HMO . . . . . . . . . .
Community Health
Center . . . . . . . . .
Medical/ Academic
health center . . . . .
Other hospital . . . .
Other health care corp
Other . . . . . . . . . .

_____

g. Does your practice have the ability to

perform any of the following on site (at
this/that in-scope location)?
1. EKG/ECG

1
2
3

2. Lab testing

1
2
3

3. Spirometry

1
2
3

4. Ultrasound

1
2
3

5. X-Ray

1
2
3

h. Do you see patients in the office during the
evening or on weekends?

1
2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK

i. What is your National Provider Identifier
(NPI) at each office location?
Notes QUESTION:
ADD
17j. What is your Federal Tax ID at each office location?

Page 8

FORM NAMCS-1A (7-25-2012)

18a. During your last normal week of practice,
how many hours of direct patient care did
you provide?

Number of
weekly hours

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

b. During your last normal week of practice,
about how many encounters of the
following type did you make with patients:
(1) Nursing home visits
(2) Other home visits
(3) Hospital visits

..................

....................

.......................

(4) Telephone consults

..................

(5) Internet/e-mail consults . . . . . . . . . . . . . . .

Add Question 19 on Practice size
Add Questions 20 through 29 on Physician Workforce

Number of encounters
per week

If one location listed in NAMCS-1A display the following:
19. How many physicians, including you, are associated with this practice? Please include physicians at this location, and
physicians at any other locations of this practice.
a) 1 physician
b) 2-3 physicians
c) 4-10 physicians
d) 11-50 physicians
e) 51-100 physicians
f) More than 100 physicians
If two or more locations listed in NAMCS-1A, display the following text and question:
The next questions are about the location where you see the most patients.
19. How many physicians, including you, are associated with that practice? Please include physicians at [fill address of
location where physician sees the most patients based on NAMCS-1A], and physicians at any other locations of that
practice.
a) 1 physician
b) 2-3 physicians
c) 4-10 physicians
d) 11-50 physicians
e) 51-100 physicians
f) More than 100 physicians
20. Is [this (if one location)/that (if two or more locations)] practice certified as a patient-centered medical home?
A Patient-Centered Medical Home (PCMH) is a team-based model of care led by a personal physician who provides
continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is
responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified
professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with
end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician,
works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care
quality and safety.(From ACP online)
a. Yes
i. If yes, by whom
1. The Accreditation Association for Ambulatory Health (AAAH)
2. The Joint Commission
3. The National Committee for Quality Assurance (NCQA)
a. [If yes:] What level of certification?
i. Level 1
ii. Level 2
iii. Level 3
4. Utilization Review Accreditation Commission (URAC)
5. Other:
6. Unknown
b. No
c. Unknown
21. How many of the following providers are on staff at the office location where you see the most patients? Please provide the
total number.
Type of Provider
Physicians (MD and DO)
Non-Physician Clinicians
Physician Assistant (PA)
Nurse Practitioner (NP)
Certified Nurse Midwife (CNM)

Number Full-time (>30
hours)

Number Part-time
(<30 hours)

Other Nursing Care
Registered nurse (RN) (not an NP or CNM)
Licensed Practical Nurse (LPN)
Certified Nursing Assistant/Aide (CNA)
Allied Health
Medical Assistant (MA)
Radiology Technician (RT)
Laboratory Technician (LT)
Physical Therapist (PT)
Pharmacist (Ph)
Dietician/Nutritionist (DN)
Other
Mental Health Provider (MH)
Health Educator/Counselor (HEC)
Case Manager (not an RN)/Certified Social
Worker (CSW)
Community Health Worker (CHW)
22. At the office location where you see the most patients, which type of provider most commonly performs the following
tasks? Enter all that apply.
Drop-down list
Based on the staff selected in Q2, a drop-down list will be made available in Q3, but will
only contain those selected providers as well as ‘NA-not applicable’ if needed. The same
drop down list will be provided for A-M.
A. Records body measurements (such as height and weight) and vital signs (such as BP,
temperature, heart rate)
B. Performs office-based testing such as EKG and hearing/vision testing (do not include
laboratory testing)
C. Draws blood for lab testing
D. Provides immunizations (includes both childhood and adult)
E. Conducts cancer screenings ( such as breast, cervical, and prostate screenings)
F. Provides behavioral health screenings (such as depression, alcohol and substance abuse)
G. Provides counseling services (such as diet/nutrition, weight reduction, tobacco cessation,
stress management)
H. Manages the routine care of patients with chronic conditions (such as hypertension,
asthma, diabetes)
I. Writes refill prescriptions for medications
J. Enters patient information into medical/billing records
K. Performs imaging tests (such as X-rays and ultrasounds)
L. Make referrals (for example, to specialty care, or to community-based services)
M. Contacts patients, who are transitioning from hospital or nursing home back to the
community
23. The following questions concern the mid-level providers practicing at the location where you see the most patients.
4a. Physician Assistant
Are PA(s) supervised by someone on-site?
Do you sign-off on the medical records of the patients the
PA(s) see(s)?
Do the PA’s patients have a separate log from your
patients?
Is your approval required before the PA(s) prescribe(s)
medication?

Yes,
always

Yes,
sometimes

No Unknown/Not
Applicable

4b. Nurse Practitioner
Are NP(s) supervised by someone on-site?
Do you sign-off on the medical record of the patients the
NP(s) see(s)?
Do the NP’s patients have a separate log from your
patients?
Is your approval required before the NP(s) prescribe(s)
medication?
Do/does the NP(s) bill for services using their own NPI
number?
4c.Certified Nurse Midwife

Yes,
always

Yes,
sometimes

No Unknown

Yes,
always

Yes,
sometimes

No Unknown

Are CNM(s) supervised by someone on-site?
Do you sign-off on the medical record of the patients the
CNM(s) see(s)?
Do the CNM’s patients have a separate log from your
patients?
Is your approval required before the CNM(s) prescribe(s)
medication?
Do/does the CNM(s) bill for services using their own NPI
number?
24. Is it possible within your practice to access patient medical records 24-hours a day?
a. Yes
[If yes:] Is this access available to physicians only, or is it also available to other non-physician clinicians?
i. Physicians (MD/DO) only.
ii. All Physicians and Non-physician Clinicians.
iii. Unknown
b. No
c. Unknown
25. What is the primary method by which your practice receives information about patients in your practice when they have
been seen in the emergency department or hospitalized? (Mark all that apply)
a. Electronic transmission (i.e., EHR or EMR)
b. Fax
c. Email
[If yes:] Was this email sent over a secure network?
i. Yes
ii. No
iii. Unknown
d. Telephone or in-person communication with provider
e. Paper copy
f. Other
26. Is someone in your practice responsible for assisting patients to safely transition back to the community within 72 hours
of being discharged from a hospital or nursing home?
a. Yes
b. No
c. Unknown
27. Does your practice report any quality measures or quality indicators to either payers or to organizations that monitor
health care quality?
a. Yes
b. No
28. A Tax Identification Number, or TIN, is required by payers such as Medicare to pay physician claims. What is the Tax
Identification Number that you use?

29. Do all other locations or offices associated with this practice use the same Tax Identification Number, or TIN, or do any
locations or offices associated with this practice use a different TIN?
a. All use the same TIN
b. Some use a different TIN
c. Unknown

Section II – INDUCTION INTERVIEW – Continued

Add Question:
31c. Does your current system meet meaningful use criteria as defined by the Department of Health
and Human Services?
1 Yes
2 No
3 Unknown

Answer ALL remaining questions for the
in-scope location/practice with the most visits.

19a. Does your practice submit any claims
electronically (electronic billing)?
30
b. Do you or your staff verify an individual
patient’s insurance eligibility electronically?

1
2
3
1
2
3

c. How do you or your staff electronically verify
an individual patient’s insurance eligibility?
Is it through an EHR/EMR system, a
stand-alone practice management system,
or some other electronic system?

d. When you electronically verify a patient’s
insurance eligibility, do you usually get
results back before the patient leaves the
office?

20a. Does your practice use an electronic health
(EHR) or electronic medical record
31a record
(EMR) system? Do not include billing record
systems.

1
2
3
4
1
2
3
1
2
3
4

Yes
No
Unknown
Yes – Go to 19c
No
Unknown
Stand-alone practice management system
EHR/EMR system
Another electronic system
Unknown
Yes
No
Unknown

}

b. In which year did your practice install your

Year

EHR/EMR system?

d. c. What is the name of your practice’s current
EHR/EMR system?
ADD Checkboxes:
Enter (X) only one box.
2 Amazing Charts
3 athenahealth
6 e-MDs
12 Practice Fusion
e. d. At your practice, are there plans for installing
a new EHR/EMR system within the next 18
months?

1
2
3
4
5
6

1
2
3
4

FORM NAMCS-1A (7-25-2012)

}

Yes, all electronic
Go to Question 20b
Yes, part paper and part electronic
No
SKIP to Question 21a on page 10
Unknown

Allscripts
Cerner
eClinicalWorks
Epic
GE/Centricity
Greenway Medical

7
8
9
10

McKesson/Practice Partner
NextGen
Sage/ViteraMedical
Other

11

Yes
No
Maybe
Unknown
Page 9

Section II – INDUCTION INTERVIEW – Continued

21a. Medicare and Medicaid offer incentives to
that demonstrate "meaningful use
32a practices
of health IT." At your practice, are there plans
to apply for these incentive payments?

b. When did you first apply?

1
2
3
4
1
2
3

c. When do you intend to first apply?

1
2
3

Yes, we already applied – Go to 21b
Yes, we intend to apply – Go to 21c
Uncertain if we will apply
No, we will not apply
2011
2012
Unknown 2013
2012 2013
2013 or later
Unknown

4 Unknown

2014 or later

Notes

Page 10

FORM NAMCS-1A (7-25-2012)

Section II – INDUCTION INTERVIEW – Continued

22. Give FLASHCARD C-1 (p.17 Flashcard booklet) and ask:
Please indicate whether your practice has each
33 of
the following computerized capabilities and
how often these capabilities are used.
Enter (X) only one per row.

Yes,
used
routinely

Yes, but
NOT
used
routinely

Yes, but
turned
off or not
used

No

Unknown

Skip to
22b

Skip to
22b

a. Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
22a(1)
If Yes, ask – (1) Does this include a patient problem list?

3

Skip to
22b

4

5

1

2

3

4

5

b. Recording and charting vital signs? . . . . . . . . . . .

1

2

3

4

5

c. Recording patient smoking status? . . . . . . . . . . . .
d. Recording clinical notes? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

1

2

3

4

Go to
22d(1)
If Yes, ask – (1) Do the notes include a list of the

patient’s medications and allergies?
Insert 33e.
f. e. Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . . .
If Yes, ask – (1) Are prescriptions sent electronically
to the pharmacy?

1

If Yes, ask – (2) When orders for prescriptions are
submitted electronically, are they
submitted by the prescribing practitioner,
or by someone else? Enter all that apply.

1

2

Go to
22e(1)
1

If Yes, ask – (3) Are warnings of drug interactions or
contraindications providers?
f. Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . . .
g. Providing standard order sets related to a
particular condition or procedure? . . . . . . . . . . . .
h. Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . .

1
2
3

l. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . .

3
3

Skip to
22f
3

Skip to
22e(2)

Skip to
22e
4
4

Skip to
22f
4

Skip to
22e(3)

5

Skip to
22e
5
5

Skip to
22f
5

Skip to
22e(3)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

1

1
2
3
1

Go to
22i(1)

j.

Go to
22e(2)

Skip to
22e

Prescribing practitioner
Someone else
Unknown

Go to
22h(1)
2

Go to
22h(2)
If Yes, ask – (2) When orders for lab tests are
submitted electronically, are they
submitted by the prescribing practitioner,
or by someone else? Enter all that apply.

Go to
22e(2)
2

Go to
22h(1)
If Yes, ask – (1) Are orders sent electronically?

Go to
22d(1)
2

Go to
22e(2)

g.

Go to
22a(1)

Go to
22h(2)

3

Skip to
22i
3

Go to
22h(2)

4

Skip to
22i
4

Skip to
22i

5

Skip to
22i
5

Skip to
22i

Prescribing practitioner
Someone else
Unknown
2

Go to
22i(1)

3

Skip to
22j

4

Skip to
22j

5

Skip to
22j

If Yes, ask – (1) Can the EHR/EMR automatically
graph a specific patient’s lab
results over time?

1

2

3

4

5

Viewing imaging results? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

k. Viewing data on quality of care measures?
. . . . . educational
2
3
4 specific 5conditions?
Identifying
resources
for
patients'
1
l. Reporting clinical quality measures to federal
or state agencies (such as CMS
or Medicaid)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FORM NAMCS-1A (7-25-2012)

1

2

3

4

5

Page 11

Section II – INDUCTION INTERVIEW – Continued

22. Please indicate whether your practice has each
of the following computerized capabilities and
33 how
often these capabilities are used.
Enter (X) only one per row.
m. Generating lists of patients with particular
health conditions? . . . . . . . . . . . . . . . . . . . . . . . . . .
n. Electronic reporting to immunization
registries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes,
used
routinely

2

1
1

o. Providing patients with clinical summaries for
each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. Exchanging secure messages with patients? . . .
q. Providing patients with an electronic copy
r. of their health information? . . . . . . . . . . . . . . . . . .

Insert
23a. Do you share any patient health information
(electronically, not fax) with other providers,
34a including
hospitals, ambulatory providers, or

Yes, but
turned
off or not
used

No

3

2

Go to
22n(1)
If Yes, ask – (1) Is the electronic reporting to
immunization registries reported in
standards specified by Meaningful
Use criteria?

Yes, but
NOT
used
routinely

4

3

Go to
22n(1)

Unknown

5

4

Skip to
22o

5

Skip to
22o

Skip to
22o

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1
2

Yes
No

labs?
b. How do you electronically share patient health
information?

1
2
3

EHR/EMR
Web portal (separate from EHR/EMR)
Other electronic method – Specify

24. Give FLASHCARD C-2 (p.18 Flashcard Booklet) and ask:
Ambulatory
Ambulatory
indicate which types of health data you Hospitals with
providers Hospitals with
providers
35 Please
which
you
are
share electronically (not fax) with the health
inside your which you are outside your
care providers listed. Enter all that apply.

affiliated

office/group

not affiliated

office/group

a. Lab results? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

b. Imaging reports? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

c. Patient problem lists . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

d. Medication lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

e. Medication Allergy lists . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

f.

1

Do you share any of the previously mentioned
types of information using a "Summary Care
Record"? [A Summary Care Record is an electronic file
that contains the previously mentioned health data in a
standardized format.]

2
3

Yes
No
Unknown

NotesReconciling lists of patient medications to identify the most accurate list?
33e.
33r. Providing patients the ability to view online, download or transmit information from their medical
record?

Page 12

FORM NAMCS-1A (7-25-2012)

36. Do you refer any of your patients 36a. Do you receive a report back from 36b. Do you receive
to providers outside of your
the other provider with results of
it electronically (not fax)?
the consultation?
office or group?
1 Yes, routinely
1 Yes  Go to Question 21a
1 Yes, routinely
2 Yes, but not routinely
2 No  Skip to Question 22
2 Yes, but not routinely
3 No
3 No  Skip to Question 22

□
□

37. Do you see any patients referred
to you by providers outside of
your office or group?

□1
□2

□
□
□

□
□
□

Yes  Go to Question 22a
No  Skip to Question 23

37a. Do you receive notification of
both the patient’s history and
reason for consultation?

□1
□2
□3

Yes, routinely
Yes, but not routinely
No  Skip to Question 23

37b. Do you receive
them electronically (not fax)?

□1
□2
□3

Yes, routinely
Yes, but not routinely
No

38. Do you take care of patients after 38a. Do you receive all of the
38b. Is the information available
they are discharged from an
information you need to continue
when needed?
managing the patient?
inpatient setting?
1 Yes, routinely
1 Yes  Go to Question 23a
1 Yes, routinely
2 Yes, but not routinely
2 No  Skip to Question 24
2 Yes, but not routinely
3 No  Skip to
3 No  Skip to Question 24
Question 24
38c. Do you receive it electronically (not fax)?

□
□

□
□
□

□1 Yes, routinely

□
□
□

□2 Yes, but not routinely

□3 No

Section II – INDUCTION INTERVIEW – Continued
Yes,
routinely

Yes, but
NOT
routinely

No

Does
not
apply

25a. When you refer your patient to a provider
outside of your office or group, do you receive
a report back from the other provider with results
of the consultation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Do you receive it electronically (not fax)? . . . . . . . . . .
c. When you see a patient referred to you by a
provider outside of your office or group, do you
receive notification of both the patient’s history
and reason for consultation? . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

Go to
25b

Go to
25b

Skip to
25c

Skip to
25c

1

2

1

3

2

Go to
25d

3

Go to
25d

Skip to
26

4

4

Skip to
26

d. Do you receive them electronically? . . . . . . . . . . . . . . . .

1

2

3

4

26. When your patient is discharged from an inpatient
setting, do you receive all of the information you
need to continue managing the patient? . . . . . . . . . . . .

1

2

3

4

a. Is the information timely, available
when needed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

b. Do you receive it electronically (not fax)? . . . . . . . . . .

1

2

3

4

39

Give FLASHCARD D (p. 19 Flashcard Booklet) and ask: The
following questions are about your practice
revenue and contracts with managed care plans.

27. Roughly, what percent of your patient care revenue
comes from –

Percent of patient care
revenue

(1) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(2) Medicaid?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(3) Private insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(5) Other? – (including charity, research, Tricare, VA, etc.) . . . . .

%

40
28. Roughly, what percentage of the patient care
revenue received by this practice comes from
managed care contracts?

FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.
Percent of revenue from
managed care

%

Edit
FORM NAMCS-1A (7-25-2012)

Page 13

Section II – INDUCTION INTERVIEW – Continued

29. Give FLASHCARD E (p.20 Flashcard Booklet) and ask:
what percent of your patient care revenue
41 Roughly,
comes from each of the following methods of

Percent of patient care
revenue

payment?
(a) Fee-for-service? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(b) Capitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(c) Case rates (e.g., package pricing/episode
of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
%

(d) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FR NOTE – Categories should sum close
to 100%. Do not leave blank or use dash to
indicate 0 percent, include value.

30a. Are you currently accepting "new" patients into your
practice(s) (at in-scope locations)?
42a

3

Yes – Go to 30b
No
Don’t know

(1) Capitated private insurance? . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(2) Non-capitated private insurance?

.............

1

Yes

2

No

3

Don’t know

(3) Medicare?

..................................

1

Yes

2

No

3

Don’t know

(4) Medicaid?

..................................

1

Yes

2

No

3

Don’t know

(5) Workers compensation? . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(6) Self-pay?

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Fixed salary
Share of practice billings or workload
Mix of salary and share of billings or other
measures of performance (e.g., your own
billings, practice’s financial performance,
quality measures, practice profiling)
Shift, hourly or other time-based payment
Other

1
2

b. From those "new" patients, which of the following

types of payment do you accept (at in-scope locations)?

...................................

(7) No charge?

.................................

31. Which of the following methods best describes your
basic compensation?
43

2
3

4
5

32. Clinical practices may take various factors into
account in determining the compensation (salary,
44 bonus, pay rate, etc.) paid to the physicians in the
practice. Please indicate whether the practice
explicitly considers each of the following factors in
determining your compensation.

1
2
3
4

Enter all that apply.
5

33a. Roughly, what percent of your daily visits are
45a same day appointments?
b. Does your practice set time aside for same
day appointments?

%
1
2
3

c. On average, about how long does it take to get

1

an appointment for a routine medical exam?

2
3
4

Page 14

Factors that reflect your own productivity
Results of satisfaction surveys from
your own patients
Specific measures of quality, such as rates
of preventive services for your patients
Results of practice profiling, that is,
comparing your pattern of using medical
resources with that of other physicians
The overall financial performance of the
practice

Yes
No
Don’t know
Within 1 week
1–2 weeks
3–4 weeks
1–2 months

5
6
7

3 or more months
Do not provide routine
medical exams
Don’t know
FORM NAMCS-1A (7-25-2012)

DELETE Page
Section II – INDUCTION INTERVIEW – Continued

34.

Do you see any patients for whom you provide
asthma diagnosis, education and/or ongoing
clinical management?

1
2

35.

Yes – If yes, asthma supplement will be
left with the respondent.
No

Note – Respondents are to answer all items (1 – 9); even if answering "No" for one item, one must still
complete the remaining items
The following questions are about complementary and alternative medicine, or "CAM," and
how you may utilize it in your medical practice. Some CAM therapies are now commonly
used, and you may think of them as mainstream.

a. During the past 12 months, did you recommend
any of the following therapies or practices to
patients? Please select "Yes" or "No" for each.

Yes
Go to 35b for
that item

No
Skip to 35f for
that item

1. Herbs and other non-vitamin supplements . . . . . . . . . . . .

1

2

2. Mind-body therapies [Such as guided imagery,
meditation, and progressive muscle relaxation (does
not include prayer)] . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3. Chiropractic or osteopathic manipulation . . . . . . . . . . . . .

1

2

4. Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

5. Naturopathic treatment . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

6. Massage therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

7. Homeopathic treatment . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

8. Biofeedback or hypnosis . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

9. Yoga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Note – Respondents are to answer all items (1 – 9); even if answering "Never," "Don’t know," or "Refusal" for
one item, one must still complete the remaining items

b. During the past 12 months, how often did
each of the following therapies arise in
conversation between you and your
patients? Would you say –

Rarely Sometimes Often
Go to
Go to
Go to
35c for
35c for
35c for
that item that item that item

Never
Don’t know
Skip to
Skip to
35d for
35d for
that item that item

Refusal
Skip to
35d for
that item

1. Herbs and other non-vitamin supplements . . . . .

1

2

3

4

5

6

2. Mind-body therapies [Such as guided imagery,
meditation, and progressive muscle relaxation
(does not include prayer)] . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

a. 3. Chiropractic or osteopathic manipulation . . . . . .

1

2

3

4

5

6

4. Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

5. Naturopathic treatment . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

6. Massage therapy . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

7. Homeopathic treatment . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

8. Biofeedback or hypnosis . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

9. Yoga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

6

FORM NAMCS-1A (7-25-2012)

Page 15

DELETE Page
Section II – INDUCTION INTERVIEW – Continued

35c. Thinking back to these conversations, who
brought up the topic of the following therapies
most often?

Patients

Physician

About equal

1. Herbs and other non-vitamin supplements . . . . . . . . . . .

1

2

3

2. Mind-body therapies [Such as guided imagery,
meditation, and progressive muscle relaxation (does
not include prayer)] . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

3. Chiropractic or osteopathic manipulation . . . . . . . . . . . .

1

2

3

4. Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

5. Naturopathic treatment . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

6. Massage therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

7. Homeopathic treatment . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

8. Biofeedback or hypnosis . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

9. Yoga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

d. Did you recommend (Therapy) to patients for any

No

Yes

of the following reasons? Please select "Yes" or "No"
for each.
1. For physical symptoms, such as pain . . . . . . . . . . . . . . .

1

2

2. For emotional symptoms, such as stress or anxiety . . . . .

1

2

3. For general health maintenance and wellbeing . . . . . . . .

1

2

4. Because the patient asked for it . . . . . . . . . . . . . . . . . . .

1

2

5. OTHER reasons

e. Which of the following factors influenced your

No

Yes

decision to recommend (Therapy) to patients?
Please select "Yes" or "No" for each.
1. Personal experience . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

2. Patient reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3. Colleague recommendation . . . . . . . . . . . . . . . . . . . . . .

1

2

4. Evidence in peer-reviewed literature . . . . . . . . . . . . . . . .

1

2

5. OTHER reasons

f. Which of the following factors prevented you from

No

Yes

recommending (Therapy) to patients? Please select
"Yes" or "No" for each.
1. Limited health insurance coverage . . . . . . . . . . . . . . . . .

1

2

2. Lack of affordability for the patient . . . . . . . . . . . . . . . . .

1

2

3. Lack of information sources . . . . . . . . . . . . . . . . . . . . . .

1

2

4. Lack of places/providers to refer patients . . . . . . . . . . . .

1

2

5. Patient’s lack of interest or openness to (Therapy) . . . .

1

2

6. Lack of perceived benefit . . . . . . . . . . . . . . . . . . . . . . . .

1

2

7. OTHER reasons
Page 16

FORM NAMCS-1A (7-25-2012)

Section II – INDUCTION INTERVIEW – Continued

36. Provider demographics –
46
a. What is your year of birth?
b. What is your sex?

1 9
1
2

c. Give FLASHCARD G (p. 22 Flashcard Booklet) and ask:
What is your highest medical degree?

1
2
3
4
5
6

Male
Female

}

MD
Go to item 36d
DO
Nurse practitioner
Physician assistant
Nurse midwife
Other

d. What is your primary specialty?
Name of specialty

Code

Name of specialty

Code

e. What is your secondary specialty?

f. What is your primary board certification?
Board certification

g. What is your secondary board certification?
Board certification

h.

What year did you graduate medical school?
Year

i. Did you graduate from a foreign medical school?

1
2

FORM NAMCS-1A (7-25-2012)

Yes
No

Page 17

47
Section II – INDUCTION INTERVIEW – Continued
37. Who will be helping you at each location? (Below enter the location and person’s name and position.)
Office
No.

NOTE: Keep the location numbers the same as the office numbers in item 15a.
Location
Name
(Enter street name)

Position

1
2
3
4
NOTE – We will review some of the questions found on the Patient Record form. Go to page 19 for instructions.
Visit Sampling
To select a sample of patient visits, the physician’s office will need to know where to start sampling (Start With) and how
to select subsequent patient visits (Take Every).
To determine the Take Every (TE) number, the system automatically calculates the intersection of the "Estimated visits for
week" column (corresponding to the total entry in ITEM 16e) with the "Days physician will see patients that week" line
(based on the entry in ITEM 16a).
TAKE EVERY NUMBER
Estimated Visits for Week

Days physician will see patients that week
1

2

3

4

5

6

7

0–12 . . . . . . . . . . . . . . . . . . . . . . .

1

1

1

1

1

1

1

13–24 . . . . . . . . . . . . . . . . . . . . . .

2

1

1

1

1

1

1

25–39 . . . . . . . . . . . . . . . . . . . . . .

3

2

1

1

1

1

1

40–44 . . . . . . . . . . . . . . . . . . . . . .

4

2

2

1

1

1

1

45–49 . . . . . . . . . . . . . . . . . . . . . .

4

2

2

2

2

2

2

50–64 . . . . . . . . . . . . . . . . . . . . . .

5

3

2

2

2

2

2

65–74 . . . . . . . . . . . . . . . . . . . . . .

10

3

2

2

2

2

2

75–89 . . . . . . . . . . . . . . . . . . . . . .

10

4

3

2

2

2

2

90–104 . . . . . . . . . . . . . . . . . . . . .

10

4

3

3

3

3

3

105–114 . . . . . . . . . . . . . . . . . . . .

10

5

3

3

3

3

3

115–129 . . . . . . . . . . . . . . . . . . . .

10

5

4

3

3

3

3

130–134 . . . . . . . . . . . . . . . . . . . .

15

10

4

3

3

3

3

135–154 . . . . . . . . . . . . . . . . . . . .

15

10

4

4

4

4

4

155–174 . . . . . . . . . . . . . . . . . . . .

15

10

5

4

4

4

4

175–194 . . . . . . . . . . . . . . . . . . . .

15

10

5

5

5

5

5

195–209 . . . . . . . . . . . . . . . . . . . .

20

10

10

5

5

5

5

210–219 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

5

5

5

220–254 . . . . . . . . . . . . . . . . . . . .

20

10

10

10

10

10

10

255–319 . . . . . . . . . . . . . . . . . . . .

25

15

10

10

10

10

10

320–364 . . . . . . . . . . . . . . . . . . . .

30

15

10

10

10

10

10

365+ . . . . . . . . . . . . . . . . . . . . . . .

30

30

30

30

30

30

30

Take Every Number
Page 18

FORM NAMCS-1A (7-25-2012)

48

Section II – INDUCTION INTERVIEW – Continued

38. START WITH NUMBER
The system automatically determines the Start With
(SW) number based on the previoiusly calculated
Take Every number. Based on the Take Every
number, a corresponding Start With number is
assigned, as shown in the table to the right.

If the Take
Every Number is:

Then the Start
With Number is:

1
2
3
4
5

Start With Number

10
15
20
25
30
INSTRUCTIONS
(1) Who to list/who not to list on the Patient Visit Worksheet found in the back of the NAMCS-26
• List every ambulatory patient visit to all in-scope locations during the reporting period.
• INCLUDE patients the physician doesn’t see but who receive care from an assistant, nurse, nurse
practitioner, physician assistant, etc.
• EXCLUDE patients who do not seek care or services (e.g., they come to pay a bill or leave a specimen).
• EXCLUDE telephone contacts with patients.

FORM NAMCS-1A (7-25-2012)

Page 19

Section III – NONINTERVIEW

39. What is the reason the provider did not participate in
this study?
49

1
2
3
4

Explanations for noninterview codes 6 and 11 –

5

• Temporarily not practicing –Refers to duration
of 3 months or more

Refused/Breakoff – SKIP to item 41a
Non-office based
SKIP to item 40
Sees no ambulatory patients
Retired
SKIP to item 44
Deceased

}

6

}

• Unavailable during reporting period –Absence
must be for duration of LESS than 3 months
11

Edit

40. Check all that apply to describe provider’s practice or
medical activities which define him/her as ineligible or
50 out-of-scope.

12
1
2
3
4
5
6
7

41a. At what point in the interview did the refusal/break-off
occur?
51a
(Enter (X) one.)

1
2
3
4
5
6

b. By whom?
(Enter (X) one.)

}

1
2
3
4
5
6

SKIP to item 40

Unavailable during reporting period – SKIP to item 42
on page 21
Moved out of PSU – SKIP to item 43a on page 21
Federally employed
Radiology, anesthesiology or pathology
specialist
Administrator
Work in institutional setting
Work in hospital emergency
department or outpatient department
Work in industrial setting
Other – Specify

}

SKIP to
item 44
page
22

During telephone screening
During induction interview
After induction but prior to assigned
reporting days
At reminder call
During assigned reporting days or
mid-week calls
At follow-up contact
Sampled provider
Sampled provider through nurse
Nurse/Secretary
Receptionist
Office manager/Administrator
Other office staff – Specify

c. What reason was given? (Verbatim)

d. Date refusal/breakoff was reported to supervisor

e. Conversion attempt result

Month

1
2
3

Page 20

Day

Year

}

No conversion attempt
SKIP to item 44 on
Sampled provider refused page 22
Sampled provider agreed to see
Field Representative – Complete Section II
FORM NAMCS-1A (7-25-2012)

Section III – NONINTERVIEW – Continued

}

42. Why is provider unavailable or not in practice?

52

43a. What is the provider’s new address?

SKIP to
item 44 on
page 22

Number and street

53a
City, State, ZIP Code

Telephone

b. Name of Field Representative

RO

PSU

Date transferred

Continue
with item
44 on
page 22

NOTES

FORM NAMCS-1A (7-25-2012)

Page 21

Section IV – DISPOSITION AND SUMMARY

44. FINAL DISPOSITION
54 (a) Eligible physician/provider

}

45. CASE SUMMARY
55 1. Number of patient visits

1

Completed Patient Record forms

2

Out-of-scope (Item 35,
codes 2, 3, 4, 5, 6, 8, 9, or 10)
Refused-Breakoff (Item 35,
code 1)
Unavailable during
reporting period (Item 35,
code 11)
Moved out of PSU (Item 35,
code 12–final)
Can’t locate (Item 35
code 7)

3
4

5
6

during reporting week . . . . . .

➜

2. Number of days during
reporting week on which
patients were seen . . . . . . . .

End of Interview
–Make certain
all items are
accurately
completed
before returning
materials to the
office.

3. Number of patient record
forms completed . . . . . . . . . . .
NOTE – For items 45(1) and 45(3),
see instruction below.

(b) Unused CHC NAMCS-1
7

Less than 3 providers sampled

8

Parent CHC Out-of-scope

9

Parent CHC Refused to participate

(c) Transfer cases
Moved out of PSU (Item 35,
code 12 –pending)
Edit

PLEASE
READ
BEFORE
CONTINUING

Edit

Item 45(1) – Accurate determination of "Number of patient visits during reporting week" is
EXTREMELY IMPORTANT! This count is to include any days the provider may have skipped
or not participated. This information may be obtained from either the office staff or from the PRF
Folio cover. Only inlcude visits to sampled provider and NOT the total number of visits to entire
practice or clinic.
Item 45(3) – If the number of Patient Record forms completed is less than 20 or greater than
40, then explain why in the NOTES section below.
Items 17e and 45(1) – If applicable, record explanation of why items 17e and 45(1) differ
significantly and any other information regarding this case which may help to understand it at a
later date.

Notes

Page 22

FORM NAMCS-1A (7-25-2012)

56

Part 3 — Missing Patient Record Form Items (1–13)

46. List missing items, and refer to the FR manual for guidelines on retrieving missing information.
Patient Record
number

Item
number(s)

Comments

(b)

(c)

(a)

47. Was provider/office staff contacted for any reason during the editing process?
57
Yes
No
48. For all Final = 1 cases, transfer information from front of Patient Record Folio.
58
FROM
TO
Month

Day

Month

Day

WEEK OF –
SURVEY WEEK
Complete a Patient
Record for patient
SW

Mon.

Tues.

Wed.

Thur.

Fri.

Sat.

Sun.

Total

Number
of patient
visits

and
every

TE

nth
patient thereafter.

Number
of
records
completed

NOTES

FORM NAMCS-1A (7-25-2012)

Page 23