Att BB - NAMCS 2012 - Patient Record Form CPT Code Prete

Attachment BB- National Ambulatory Medical Care Survey 2012: Patient Record Form – CPT Code Pretest
NOTICE: Public reporting burden of this collection of information is estimated to average 14 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 the 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).
OMB No. 0920-0234: Approval expires 03/31/2013

Please indicate all CPT codes associated with the current visit:
1.
2.
3.
4.
5.

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6.
7.
8.
9.
10.

__/__/__/__/__
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□

No CPT codes associated with the current visit.

11.
12.
13.
14.
15.

__/__/__/__/__
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__/__/__/__/__
__/__/__/__/__
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