[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON) /(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, ENTER 1 FOR DOLLARS, THEN RESPONSE.
IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1
PERCENT ................................ 2 [CP11OV2]
[Code One]
PRESS F1 FOR INFORMATION ON AMOUNTS TO INCLUDE.

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
ROSTER. SOURCE OF PAYMENT
DOLLAR AMOUNT PAID
PERCENT AMOUNT PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Display $ Amount] [Display % Amount]
TOTAL CHARGE: [$XXXXXXXXX]
[Did (PROVIDER) discount any portion of the total charges/ Was any portion of the total charges discounted]?

YES .................................... 1
NO ..................................... 2 [BOX_11]
REF ................................... -7 [BOX_11]
DK .................................... -8 [BOX_11]
PRESS F1 FOR DEFINITION OF DISCOUNTED.
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER THAT ARE FLAGGED AS 'DIRECT PAYMENT' AND THE ASSOCIATED DIRECT PAYMENT AMOUNTS.
----------------------------------------------------
----------------------------------------------------
SOURCE OF PAYMENT MATRIX IS READ ONLY.
DISPLAY '(PROVIDER) DISCOUNTED ANY PORTION OF THE TOTAL CHARGES' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM. DISPLAY 'ANY PORTION OF THE CHARGE WAS DISCOUNTED' IN THE QUESTION TEXT IF THE EVENT TYPE IS PM OR OM.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
How much was the discount?
IS ANSWER IN DOLLARS OR PERCENT?

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [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).
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Does anyone in the family or any other source expect to make additional payments for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE)/services received at home from (PROVIDER) during (MONTH) for (PERSON)/ (PROVIDER)'s services as part of the visit made on (VISIT DATE)]?

YES .................................... 1
NO ..................................... 2 [LOOP_03]
REF ................................... -7 [LOOP_03]
DK .................................... -8 [LOOP_03]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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]

[PERSON'S FIRST MIDDLE AND LAST NAME] [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)/(PROVIDER)'s services as part of the visit made on (VISIT DATE)]?
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.
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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 NULL DISPLAY.
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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.'
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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.'
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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.'
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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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