CP12
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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..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges 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)/for 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 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
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DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
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DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
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CP12A
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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...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
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ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
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WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
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SOURCE ROSTER BEHAVIOR SPECIFICATIONS:
1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
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CP13
====
[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...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
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ROSTER. SOURCE OF PAYMENT CP13_02. DOLLAR CP13_03. PERCENT AMOUNT PAID AMOUNT PAID
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PERSON/Family [Display $ Amount] [Display % Amount]
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[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
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[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
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ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
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TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
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FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
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