Attachment 13 – HC MEPS Record Keeper

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Name ________________________________

Name ________________________________

Name ________________________________

Name ________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Name ________________________________

Name ________________________________

Name ________________________________

Name ________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Name ________________________________

Name ________________________________

Name ________________________________

Name ________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Name ________________________________

Name ________________________________

Name ________________________________

Name ________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Name ________________________________

Name ________________________________

Name ________________________________

Name ________________________________

Address ______________________________

Address ______________________________

Address ______________________________

Address ______________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

Phone _______________________________

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3.6875 panel width
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MEPS
Medical Expenditure Panel Survey

Your Health Care

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

39841.0414.6050020301

OMB #0935-0118
14-450R

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3_11/16

Instructions
You may use this record
keeper to help prepare for
your MEPS interviews.
Each time you or a family
member receives health
care, record the following
information:

3.6562 panel width
3_21/32

3.625 panel width
3_5/8

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 of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________
Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

Name_________________________________

your health care

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Date of Visit ___________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

Provider Name_________________________

providers’ contact

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Reason for Visit ________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

Total Charge __________________________

information.

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Family _____________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Payment by Other ______________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

Prescriptions __________________________

• 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

On the back of the
record keeper there
is space to record