Attachment 5 – HC About the MEPS-MPC Authorization Form

...information released to
MEPS is protected by the
Public Health Service Act...

HOSPITAL STA
Y FORM

Please complete
one form for each
hospital stay.
1. Patient Na
me: __________
________________
________________
______ 
2. Admission
Date: ________
/_____ /________

_ 3. Discharge
Date: ________
MONTH
DAY
/_____ /________
YEAR
_
MONTH
4. Diagnosis
DAY
YEAR
(ICD-9’s): Primary
________ Second
ary _______ ____
___ _______ ____
___ _______
5. What was the
full established
charge for this sta
y?
$____________
________ .00
_____________
________

_______________

Q.
A.

______

Why do you need this form?
Your providers cannot release information about
you to a study like MEPS without your ­written
authorization. The Health Insurance Portability
and Accountability Act, or HIPPA for short, sets
guidelines for the authorization forms that must
be signed to allow a provider to release health care
information. The MEPS authorization form
follows these guidelines.

Q.
A.

How do you protect my information?
Just like the information you have already given to
the MEPS interviewer, any information your provider
gives us will be protected by Sections 944(c) and
308(d) of the Public Health Service Act [42 U.S.C.
299c-3(c) and 42 U.S.C. 242m(d)]. Information that
could identify you will not be disclosed unless you
have consented to that disclosure.

_
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1. The generic name of
medicine: �������������������������������
nufacturer name of the
2. The brand name or ma
lled: ________
the prescription was refi
3. The number of times
_/_____/____
_____/_____/______ ___
MO DAY YR
____/_____/____
_

d:
YR
fille
was
DAY
n
iptio
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scr
MO DAY YR
4. The dates the pre

__________
Number: _______________
dicine:
me
the
of
h
ngt
stre
he
5. T
mEq mcg % mg ml
Unit: mg gm gr

6. For each prescription:
_____ .00
Patient Payment: $_____

6. From what so
urces has the fac
ility received paym
and how much wa
ent
s paid by each so
urce?
Source _________
_______ $____
____________ .0
0
Source _________
_______ $____
____________ .0
0
Source _________
_______ $____
____________ .0
0

00 Source:��������

_____ .
Other Payments: $_______

:��������
$____________ .00 Source


The new HIPAA law creates additional protection
for personal health information held by medical providers and pharmacies. But HIPAA protections end
when the information is released to others. When
information is released to MEPS, the requirements
of the Public Health Service Act provide continuing
assurance of confidentiality.

More
Questions & Answers
Q.
A.

My providers are very busy. Isn’t this a
bother to them?

Your signature on an authorization form s­ imply gives
your doctor, hospital, or pharmacy the opportunity to
participate in the study if they choose. It allows them to
make their own decisions. Our experience indicates that
most health care providers are willing to participate in
important research such as MEPS. Usually, an office
staff person can fill out the form and the pharmacist
can produce a simple computer printout.

Q.
A.

What information will you tell my
doctor (or pharmacist) about me?
To allow medical and pharmacy staff to identify your
records, we will provide your name, date of birth,
and the signed authorization form. We also will
share other information such as your address or
name of the policyholder for your health insurance,
if needed, to help a doctor or hospital identify the
­correct records.

Q.

Will this affect my Medicare, Medicaid,
VA benefits, or any other public
assistance I am receiving?

A.

No. Signing or not signing this authoriza­tion form will
not affect your eligibility for any program benefits.

Q.

Why do you need to contact my
psychiatrist? That information
is too personal.

A.

Should they choose to participate in the study,
psychiatrists, like other doctors, will be asked about the
costs, dates, ­diagnoses, and type of service they provide.
They will not be asked about treatment details.

Q.

Why does this form have an expi­ration
date that is past the period of time you
are interested in?

A.

This is only to allow enough time for contact with all
of the health care providers in this survey. Large surveys
such as this take time.

Research groups use the results of this
survey in their attempts to improve access
to medical care for older people, veterans,
minorities, and children.

Q.

Will my doctor (or pharmacist) bill me
for the time he or she spent participating
in this survey?

A.

Q.
A.

Who must sign the authorization forms?
Authorization forms for adults must be signed by the
person who received the services from the provider
or pharmacy named in Box A of the authorization
form. For teens between 14 and 17 years of age, both
the teen who received the services and a parent/
guardian must sign the form. For children age 13
or younger, only a parent or guardian must sign
the authorization form.

No. Should a doctor, hospital, or pharmacy have a
policy of charging for the information we request,
MEPS will pay this charge directly.

Q.
A.

My children have advised me not to sign
anything. Why should I?
A vital part of the research is directed at
understanding the special health care needs of older
Americans. Many research groups use the results of
this survey in their attempts to improve access to
medical care for older people. We understand that
your children only want to protect you. If they have
a particular concern that we could address, the
interviewer will be happy to talk to them or they
can call Alex Scott at 1‑800‑945‑MEPS (6377).

Q.
A.

What if I change my mind?
You can revoke an authorization at any time by
contacting the MEPS study. You can contact the
study by telephone by calling 1-800-945-MEPS (6377).
You can contact the study by mail at the
following address:

Medical Expenditure Panel Survey
ATTN: Alex Scott
c/o Westat
1600 Research Blvd. Room RE 360S
Rockville, MD 20850
If you decide to revoke an authorization, we will stop
any efforts to contact that provider. If the provider
has already given us information about you, we will
erase that information from the study records unless
it is already incorporated into research files in which
you cannot be identified.

Authorization Forms Instructions
Please follow these instructions as you review and sign authorization forms in black ink.

A
Check the name
and address of the
hospital, pharmacy, or
other medical provider.
If any of this information
is not correct, please
make changes and initial
each correction.

AUTHORIZATION TO OBTAIN INFORMATION FROM MEDICAL AND BILLING RECORDS
MEDICAL EXPENDITURE PANEL SURVEY –
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
A.

Street Address:
City:

B.

P
M

State:

Telephone:

B

(

)

-

Area Code

Zip:

E
L

I am voluntarily participating in the Medical Expenditure Panel Survey (MEPS), a study of health care use and expenses being conducted by the
U.S. Department of Health and Human Services. I authorize and request that you provide the U.S. Department of Health and Human Services and
its contractors with medical and financial information they request about all health services provided to me during the period January 1, 2018 to
December 31, 2019. This authorization form covers any care I received at your facility during this period, including treatment for mental health,
alcohol, drug abuse, STD, HIV, AIDS, or Sickle Cell Anemia. It also covers care I received during this period from any medical provider
associated with your facility or who provided care to me in your facility.

A
X

I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA)(1) prohibits you from releasing my information without
my authorization. This form (or a photocopy of this form) gives you my authorization. I have signed this form voluntarily, with the understanding
that my decision to sign or not to sign the form will have no effect on my eligibility for treatment, payment, enrollment, or eligibility for any
benefits to which I am entitled.

Read the statement.
(See enlargement on
facing page.)

I understand that the Department of Health and Human Services and its contractors will use this information to supplement the information I have
already given for MEPS research on health care use and expenditures. I also understand that once my information is released to the study, it is no
longer covered by HIPAA but is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C.
242m(d)], which provide that information that could identify me will not be disclosed unless I have consented to that disclosure.

E

I authorize the study to use information I have given in the survey to help you identify my records. I also understand that I can revoke this
authorization at any time by contacting a study representative in writing or by telephone, but that my revocation will not affect disclosures already
made by a provider relying on my authorization. Otherwise, this authorization expires 30 months from the date of signature.

C
Check the patient’s
name and date of
birth.

C.

If any of this information
is not correct, please
make changes and initial
each correction.

D.

If your records might be
filed under some other
name (a maiden name
or alternate spelling, for
example), please complete Item 3.

Provider Name:

1.
2.

4.

Patient Name:

/

Date of Birth

Month

/

Day

3. Other Names Under Which Records May be Filed
Year

5. Date Signed

Patient's Signature - 14 and over sign

IF PATIENT IS 14-17, BOTH PATIENT AND PARENT/GUARDIAN MUST SIGN AND DATE.

E.

6.

8.

Parent, Guardian, Witness or Proxy's Signature

9. Reason for Parent, Guardian, Witness or Proxy's Signature:
Patient 13 or Younger
Patient 14-17 Years Old

Signer's Relationship to Patient

FIELD USE ONLY: RU ID:
(1)

7. Date Signed

REGION:

PROVID:

Patient Disabled
Patient Deceased
PID:

Health Insurance Portability and Accountability Act: 42 U.S.C. 1320d-2 and 1320d-4 and the implementing regulation, 45 CFR 164.508, require a detailed authorization
for your health care provider to disclose health information from your records for research purposes.
Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane Room #07W42, Rockville, MD 20857.

D & E
Who should sign the form?
IF PATIENT IS:

THEN FORM SHOULD BE SIGNED BY:

a. Age 18 or older . . . . . . . . . . . . . . . . . . . . . . . . . . . Only patient for Items 4 and 5, unless one of d-f below applies
b. Age 14 through 17 . . . . . . . . . . . . . . . . . . . . . . . . . Patient and parent or guardian (Items 4-9)
c. Age 13 or younger . . . . . . . . . . . . . . . . . . . . . . . . . Parent (Items 6-9)
d. Unable to sign name but able to make mark . . . . . Witness (Items 6-9)
e. Deceased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proxy (Items 6-9)
f. Unable to sign name or make mark . . . . . . . . . . . Proxy (Items 6-9)