Survey Text

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

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018

No questionnaire text is available for this sample.


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2017

No questionnaire text is available for this sample.


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

[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW OR IS NOT ASKED.
[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.
DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).
DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).
DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).
DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).
DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).
DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).
DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).
DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).
DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).
DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).
FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0,
DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW),OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/ MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP]]
[NAME OF PRESCRIBED MEDICINE] [OME ITEM GROUP NAME]
How much of the [[AMT TOT CH]/total charge] did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements?
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'GLASSES OR CONTACT LENSES' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'AMBULANCE SERVICES' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'ORTHOPEDIC ITEMS' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'HEARING DEVICES' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'PROSTHESES' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'BATHROOM AIDS' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'MEDICAL EQUIPMENT' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'DISPOSABLE SUPPLIES' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'ALTERATIONS OR MODIFICATIONS' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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)]? Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS.

(PERSON)'s visit to (PROVIDER) on (VISIT DATE):
DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN.

the last purchase of [NAME OF PRESCRIBED MEDICINE] for (PERSON): DISPLAY IF EVENT TYPE IS PM.

[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

the services for (FLAT FEE GROUP) for (PERSON):
DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE): DISPLAY IF EVENT TYPE IS OM.

services received at home from (PROVIDER) during (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'glasses or contact lenses' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'insulin' IF THE OM ITEM GROUP IS '2' (INSULIN).

DISPLAY 'other diabetic equipment or supplies' IF THE OM ITEM GROUP IS '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES).

DISPLAY 'ambulance services' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'orthopedic items' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'hearing devices' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'prostheses' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'bathroom aids' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'medical equipment' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'disposable supplies' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'alterations or modifications' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
----------------------------------------------------

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EV] [EVN-DT/REF-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)]? Please include all amounts paid 'out-of-pocket,' that is, amounts paid before any reimbursements.
IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
DOLLARS ................................ 1 [CP11OV1]
PERCENT ................................ 2 [CP11OV2]
[Code One]
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
----------------------------------------------------
DISPLAY [NAME OF MEDICAL CARE PROVIDER] IN THE HEADER IF THE EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
OTHERWISE, USE NULL VALUE.

DISPLAY [EVN-DT] IN THE HEADER IF EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).

DISPLAY [REF-DT] IN THE HEADER IF EVENT TYPE IS 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).

DISPLAY 'REPEAT VISIT: [NAME OF REPEAT VISIT GROUP]' IN THE HEADER IF THIS EVENT IS A REPEAT VISIT STEM.

DISPLAY 'FLAT FEE GROUP: [NAME OF FLAT FEE EVENT GROUP]' IN THE HEADER IF THIS EVENT IS A FLAT FEE STEM.

[[AMT TOT CH]/total charge]: DISPLAY '[AMT TOT CH]' IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT CP09OV. DISPLAY 'total charge' IF CP08 IS CODED '2' (NO), '-7' (REFUSED), '-8' (DON'T KNOW), OR IS NOT ASKED.

[AMT TOT CH]: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
----------------------------------------------------
----------------------------------------------------
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS.

(PERSON)'s visit to (PROVIDER) on (VISIT DATE):
DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN.

the last purchase of [NAME OF PRESCRIBED MEDICINE] for (PERSON): DISPLAY IF EVENT TYPE IS PM.

[NAME OF PRESCRIBED MEDICINE]: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT.

the services for (FLAT FEE GROUP) for (PERSON):
DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

the [OME ITEM GROUP NAME] used by (PERSON) since (START DATE): DISPLAY IF EVENT TYPE IS OM.
----------------------------------------------------
----------------------------------------------------
[OME ITEM GROUP NAME]: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT.

DISPLAY 'glasses or contact lenses' IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS '1' (GLASSES OR CONTACT LENSES).

DISPLAY 'ambulance services' IF THE OM ITEM GROUP IS '4' (AMBULANCE SERVICES).

DISPLAY 'orthopedic items' IF THE OM ITEM GROUP IS '5' (ORTHOPEDIC ITEMS).

DISPLAY 'hearing devices' IF THE OM ITEM GROUP IS '6' (HEARING DEVICES).

DISPLAY 'prostheses' IF THE OM ITEM GROUP IS '7' (PROSTHESES).

DISPLAY 'bathroom aids' IF THE OM ITEM GROUP IS '8' (BATHROOM AIDS).

DISPLAY 'medical equipment' IF THE OM ITEM GROUP IS '9' (MEDICAL EQUIPMENT).

DISPLAY 'disposable supplies' IF THE OM ITEM GROUP IS '10' (DISPOSABLE SUPPLIES).

DISPLAY 'alterations or modifications' IF THE OM ITEM GROUP IS '11' (ALTERATIONS/MODIFICATIONS).

DISPLAY [TEXT FROM OTHER SPECIFY] IF THE OM ITEM GROUP IS '91' (OTHER).

FOR 'TEXT FROM OTHER SPECIFY', DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.

FOR '[START DATE]', DISPLAYED IN THE CONTEXT HEADER, DISPLAY THE START DATE OF THE CURRENT ROUND FOR OM EVENTS THAT ARE 'REGULAR' GROUP TYPE (EV02A=1 OR NOT ASKED) AND DISPLAY 'JAN 01' FOR OM EVENTS THAT ARE 'ADDITIONAL' GROUP TYPE (EV02A=2).

services received at home from (PROVIDER) during
(MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.
----------------------------------------------------

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

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

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

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
Has any [other] source already paid [(PROVIDER)] for any of the charges for [(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of [NAME OF PRESCRIBED MEDICINE...] for (PERSON)/ the services for (FLAT FEE GROUP) for (PERSON)/the [OME ITEM GROUP NAME...........] used by (PERSON) since (START DATE)/for services received at home from (PROVIDER) during (MONTH) for (PERSON)]?
YES .................................... 1
NO ..................................... 2 [END_LP01]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
PRESS F1 FOR A DEFINITION OF SOURCE AND 'ALREADY PAID'.
----------------------------------------------------
DISPLAY 'OTHER' IN THE QUESTION TEXT IF AN AMOUNT WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT ) $0 OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2
----------------------------------------------------
----------------------------------------------------
DISPLAY '(PROVIDER)' IN THE QUESTION TEXT IF EVENT TYPE IS NOT PM OR OM.
----------------------------------------------------
CP13
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.] [EV] [EVN-DT]
[REPEAT VISIT: [NAME OF REPEAT VISIT GROUP....]/FLAT FEE
GROUP: [NAME OF FLAT FEE EVENT GROUP..]]
[NAME OF PRESCRIBED MEDICINE...] [OME ITEM GROUP NAME...........]
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TO MOVE CURSOR, USE ARROW KEYS. TO LEAVE, PRESS ESC.
TOTAL CHARGE: [$XXXXXXXXX]
ROSTER. SOURCE OF PAYMENT
CP13_. DOLLAR AMOUNT PAID
CP13_03. PERCENT AMOUND PAID
PERSON/Family [Display $ Amount] [Display % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
[Display Source of Payment] [Enter $ Amount] [Enter % Amount]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL SOURCES ON THE EVENT'S-SOURCES-OF-PAYMENT-ROSTER, THAT IS, ALL SOURCES SELECTED AT CP12A FOR THIS EVENT- PROVIDER PAIR AND THE 'PERSON/FAMILY' RECORD.
----------------------------------------------------
----------------------------------------------------
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
----------------------------------------------------
----------------------------------------------------
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS 'DIRECT PAYMENT'.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

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2005
Survey form view entire document:  text  image
CP13
====

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

DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11OV1 IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN CP13_02, 'DOLLAR AMOUNT PAID'.
IF THE RESPONSE TO CP11OV2 IS A PERCENTAGE, DISPLAY THE PERCENTAGE AMOUNT IN CP13_03, 'PERCENT AMOUNT PAID'. IF CP11OV1 OR CP11OV2 IS CODED '-8' (DON'T KNOW), DISPLAY 'DK' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03. IF CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED), DISPLAY 'REF' FOR THE AMOUNT IN BOTH CP13_02 AND CP13_03.
----------------------------------------------------
----------------------------------------------------
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR CORRECTED.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE, IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN (NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS SCREEN.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID COLUMN FOR THE FIRST SOURCE ADDED/ SELECTED AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
----------------------------------------------------

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

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

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2003
Survey form view entire document:  text  image

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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