Survey Text

2016 2011 2006 2001
2015 2010 2005 2000
2014 2009 2004 1999
2013 2008 2003 1998
2012 2007 2002 1997
top
2016

No questionnaire text is available for this sample.


top
2015
Survey form view entire document:  text  image
CP09A
=====

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?
YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

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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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

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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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2010
Survey form view entire document:  text  image
CP09A
=====

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?
YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2007
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2006
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2005
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2004
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2003
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2002
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
2000
Survey form view entire document:  text  image
CP09A
=====

[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..]]
Let me be sure I recorded this correctly. The total charge for the services received at home from (PROVIDER) during (MONTH) for (PERSON) was [$ AMOUNT].
Is that correct?
YES .................................... 1 [CP11]
NO ..................................... 2
REF ................................... -7 [CP11]
DK .................................... -8 [CP11]
----------------------------------------------------
IF CODED '2' (NO), DISPLAY THE FOLLOWING MESSAGE:
'USE CTRL/B TO CORRECT TOTAL CHARGE FOR THIS MONTH. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
CP17
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]

top
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]?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP17OV2]
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?
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
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
CP21
====

[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)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[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?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]