OBNPHEXTOT
Annual total of direct health care payments to office-based non-physicians
Description
For all persons, OBNPHEXTOT captures the sum of direct payments for care provided during the year for all visits to office-based non-physicians, including out-of-pocket payments and payments by private insurance, Medicaid, Medicare, and other sources. Payments for over-the-counter drugs and indirect payments not related to specific medical events, such as Medicaid Disproportionate Share and Medicare Direct Medical Education subsidies, are not included in this amount. For more information on how MEPS collects expenditure data, please refer to our user note on medical expenditures.
Related variables
Variables related to total annual health care expenditures by source of payment, total annual health care expenditures by type of medical service, and total annual health care charges are also available. Please refer to our user note on expenditures for a list of these variables.
Codes
OBNPHEXTOT is a 6-digit numeric variable.
Universe
- 1996-2016: All persons.
Availability
- 1996-2016
Survey Text
| 2016 | 2010 | 2004 | 1998 |
| 2015 | 2009 | 2003 | 1997 |
| 2014 | 2008 | 2002 | 1996 |
| 2013 | 2007 | 2001 | |
| 2012 | 2006 | 2000 | |
| 2011 | 2005 | 1999 |
2016
Survey form
view entire document:
text
image
CP16
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[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2015
Survey form
view entire document:
text
image
CP11
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====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP16
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2014
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2013
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2012
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2011
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2010
Survey form
view entire document:
text
image
CP11
====
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP16
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2009
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2008
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2007
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2006
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2005
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2004
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2003
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2002
Survey form
view entire document:
text
image
CP18
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2001
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
2000
Survey form
view entire document:
text
image
CP11
====
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP16
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
1999
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
1998
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
1997
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
1996
Survey form
view entire document:
text
image
CP16
====
====
====
====
====
====
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?
YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
CP17
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
CP18
PERCENT ................................ 2 [CP17OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
PERCENT ................................ 2 [CP19OV2]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
====
[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
PERCENT ................................ 2 [CP22OV2]
Weights
- 1996-2016 : PERWEIGHT