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
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2017
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2016
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2015
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
1999
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
1998
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
CP12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP12A
=====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
Who else paid? PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE RU-SOURCES-OF-PAYMENT-ROSTER.
----------------------------------------------------
----------------------------------------------------
WRITE SOURCES SELECTED TO THE EVENT'S-SOURCES-OF- PAYMENTS-ROSTER.
----------------------------------------------------
----------------------------------------------------
SOURCE ROSTER BEHAVIOR SPECIFICATIONS:

1. INTERVIEWER MAY SELECT A SOURCE(S) ALREADY LISTED ON THE ROSTER.
2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF SOURCES AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF SOURCES).
3. INTERVIEWER SHOULD BE ABLE TO DELETE A SOURCE THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE A SOURCE ENTERED IN ERROR. IF DELETE IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY THE FOLLOWING ERROR MESSAGE: 'DELETE ALLOWED ONLY WHEN SOURCE IS FIRST ENTERED.'
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_02. DOLLARAMOUNT PAID
CP13_03. PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [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 CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT 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. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. 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 PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------