 
	OMB#: 0935-0118
	 
	
	 
	
	 
	
 
	Medical Expenditure Panel Survey – Medical Provider Component
	
	
Reference #: «GID
	Confidential
	Patient Checklist – (Continued)  
PLEASE RETURN
	
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				 | Provider Name | Pati7ent Name | Date of Birth | Gender | 2017 Patient | 
				Patient Located -  | 
				Is Not  | 
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document | 
| Author | Edrina Bailey | 
| File Modified | 0000-00-00 | 
| File Created | 2021-01-20 |