Survey Text

2021 2014 2007 2000
2020 2013 2006 1999
2019 2012 2005 1998
2018 2011 2004 1997
2017 2010 2003 1996
2016 2009 2002
2015 2008 2001
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2021

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2017
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2016
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2015
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
1999
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
1998
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
CP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.
CP11OV1
=======

ENTER DOLLARS:
[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
SOFT RANGE CHECK: $0 - $10,000
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_05
----------------------------------------------------
CP11OV2
=======

ENTER PERCENT:
[Enter Percent %] ......................
----------------------------------------------------
SOFT RANGE CHECK: 1% - 100%
----------------------------------------------------
----------------------------------------------------
MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT PAID BY THE FAMILY AT CP11.
----------------------------------------------------
----------------------------------------------------
IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE CALCULATED. RECORD DOLLAR AMOUNT PAID BY PERSON/FAMILY AS 'DK' OR'REF' AS APPROPRIATE.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE 'PERSON/FAMILY' TO THE EVENT'S-SOURCES-OF- PAYMENT-ROSTER.
----------------------------------------------------
CP14
====

[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...........]
Has any source reimbursed or paid back anything to (PERSON) (or anyone in the family) for the amount paid 'out-of-pocket'?
That is, has any source reimbursed any of the [$/% FAMILY PAID] paid?
YES .................................... 1
NO ..................................... 2 [END_LP02]
REF ................................... -7 [END_LP02]
DK .................................... -8 [END_LP02]
PRESS F1 FOR DEFINITION OF SOURCE AND REIMBURSEMENT.
CP14A
=====

[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 reimbursed or paid anyone in the family back?
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 Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER EXCLUDING THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
NOTE: SOURCES OF PAYMENTS AND SOURCES OF REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.
----------------------------------------------------
CP15
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CAREPROVIDER.] [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) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
PERSON/FAMILY PAYMENT: [$XXXXXXXXX] TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF
REIMBURSEMENT
CP15_02. DOLLAR AMOUNT REIMBURSED
CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
[Display Source of Reimbursement] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP14A FOR THIS EVENT- PROVIDER PAIR.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'REIMBURSEMENT'.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE REIMBURSEMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT REIMBURSED COLUMN (NEXT TO PERCENT AMOUNT REIMBURSED).
5. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT REIMBURSED.
6. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.
7. IF THE TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS THE MESSAGE: 'REIMBURSED AMOUNT GREATER THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT AND RE-ENTER. IF NEED TO CORRECT FAMILY PAYMENT, JUMPBACK TO CP13.' IF INTERVIEWER RE-ENTERS THE SAME AMOUNTS, CAPI WILL ACCEPT. THAT IS, WE WILL INFORM THE INTERVIEWER OF THE DISCREPANCY, BUT NOT FORCE HER TO RECONCILE IT.
8. THE SAME SOURCE CAN BE FLAGGED AS BOTH A REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE AMOUNT ASSOCIATED WITH THE DIRECT PAYMENT WILL PLAY INTO THE RESOLUTION PROCESS.
9. POST DATA COLLECTION EDITING WILL BE NECESSARY TO DETERMINE THE NET PAYMENTS OF SOURCES.
----------------------------------------------------