Survey Text

2021 2017 2013 2009
2020 2016 2012 2008
2019 2015 2011 2007
2018 2014 2010
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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
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2017
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2016
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2015
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2014
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2013
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

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2012
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
CP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the total charge for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
Please include any amounts that may be paid by health insurance or other sources. [However, please do not include any services billed for separately such as physician charges or other services.]
[If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.]

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.
[CODE '95' IF THIS IS A FLAT FEE SITUATION.]
AMOUNT ................................. 1
INCLUDED WITH OTHER CHARGES ........... 95
[Code One]
PRESS F1 FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE AND FLAT FEE.
----------------------------------------------------
DISPLAY 'However, please do not include any services billed for separately such as physician charges or other services.' IF EVENT TYPE IS HS, ER, OR OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY 'If charges for procedures such as x-rays, lab tests, or diagnostic procedures are listed separately on the bill or statement, include those in the total charge.' IF CP05 IS CODED '1' (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A ULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A FLAT FEE GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A REPEAT VISIT GROUP. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (INCLUDED WITH OTHER CHARGES) AND THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.
----------------------------------------------------
CP18
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Do you expect any [other] source to reimburse anyone in the family for what has been paid?
YES .................................... 1
NO ..................................... 2 [BOX_09]
REF ................................... -7 [BOX_09]
DK .................................... -8 [BOX_09]
PRESS F1 FOR DEFINITION OF REIMBURSEMENT.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF CP14 IS CODED '1' (YES).
----------------------------------------------------
CP19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP19OV2]
[Code One]
CP21
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]
CP22
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much more does anyone in the family or any other source expect to pay?
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1
PERCENT ................................ 2 [CP22OV2]
[Code One]