Form
Approved
OMB Number 0935-0118
Expiration Date 01/31/2013
VERSION 1.0
Version | Author / Title | Date | Comments |
---|---|---|---|
1.0 | Multipe RTI and SSS authors | 3/25/10 | Changes from final 2009 version made via track changes |
For each of the patient(s) you confirm as receiving care during the calendar year 2010, I’ll need to ask about services you provided and charges for those services. I will ask about each confirmed patient individually.
READ EACH PATIENT NAME FROM THE LIST. IF THE PERSON ON THE PHONE SAYS “NO”, ASK: Did the patient receive services in some year other than 2010, or do you have no records at all?
FOR EACH LISTED PATIENT, CHOOSE A RESPONSE FROM THE DROP-DOWN LIST IN THE PATIENT CONFIRMATION COLUMN BELOW.
ONCE YOU CONFIRM A PATIENT FOR 2010, CLICK ON THE NAME OF THAT PATIENT AND COMPLETE THE EVENT FORM(S) FOR THAT PATIENT.
PATIENT DISAVOWAL
Finally, I need to review with you the patient(s) in the list who you indicated did not receive care during the calendar year 2010.
CLOSE OUT THE CALL
Thank you for your time.
OMB SECTION
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
(Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.)
OMB No. 0935-0118; Exp. Date 1/31/2013
Q1. Date Filled:
MONTH: ___
DAY: ___
YEAR: ____
DK/REF/RETRIEVABLE - CONTINUE TO Q2.
Q2. Prescription information will be identified using:
NOTE: TRY TO OBTAIN NDC. USE DRUG NAME ONLY IF NDC NOT AVAILABLE.
IF R_RXIDTYPE = 1 (NDC), GO TO Q2a.
IF R_RXIDTYPE = 2 (Drug Name, Strength/Unit, & Dosage Form), GO TO Q2b.
DO NOT ALLOW DK/REF/RETRIEVABLE.
Q2a. NDC
NOTE THAT NDC FORMAT IS COMPOSED OF DIGITS AND DASHES.
IF DRUG IS A COMPOUND ENTER NDC CODE OR 99999-9999-96.GO TO Q3a/b.
Q2b. Drug Name: ___________
DK / REF / RETRIEBLE - CONTINUE TO Q2c/d.
Q2c. Strength: ________
Q2d. Unit: _______ Other, Specify: ________
NOTE: WHERE NECESSARY, YOU MAY ENTER A SECOND STRENGTH AND UNIT, FOR EXAMPLE TO DESCRIBE A SOLUTION OR CONCENTRATION (e.g., 7 mg/5 ml). OTHERWISE SKIP TO Q2e, DOSAGE FORM.
DK/REF/RETRIEVABLE, CONTINUE TO Q2e.
Q2c2. Strength 2: _______
Q2d2. Unit 2: ______ Other, Specify: __________
Q2e. Dosage Form: ______ Other, Specify: ______
CONTINUE TO Q3a/b.
Q3a. Quantity: _______.
NOTE 1: QUANTITY SHOULD REFLECT THE CONTENTS OF A CONTAINER, NOT THE NUMBER OF CONTAINERS.
EXCEPTION: IF NDC PROVIDED, THEN NUMBER OF EPIPENS CAN BE RECORDED FOR QUANTITY, AS OPPOSED TO QUANTITY OF EPIPEN CONTENTS.NOTE 2: FOR A DEVICE, ACCEPT A QUANTITY OF 1 OR 2.
EXCEPTION: IF IT APPEARS THE QUANTITY IS FOR ONE OR TWO DOSEPAKS CONTAINING MULTIPLE PILLS, THEN RECORD THE QUANTITY OF TABLETS, CAPSULES, ETC., THAT EACH DOSEPAK CONTAINS.NOTE 4: FOR OINTMENTS, CREAMS, DROPS, LIQUID, FILLED SYRINGES (EXCEPT EPIPENS) AND OTHER DOSAGE FORMS NEEDING A QUANTITY UNIT, ASK FOR THE QUANTITY OF THE OF THE CONTENTS.
ALLOW DK/RF/RETRIEVABLE.
POST-LOGIC FOR Q3a: AFTER RECORDING Q3a, IF R_RXIDTYPE=1 AND NDC NE DK/RF/RET, SKIP USER TO R_DAYSSUP
DK/REF/RETRIEVABLE - CONTINUE TO Q3b.
Q3b. Quantity Unit: _________ OTHER, PLEASE SPECIFY: _________
DK/REF/RETRIEVABLE - CONTINUE TO Q4.
Q4. How many days were supplied? __________
NOTE: IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999.
DK/REF/RETRIEVABLE - CONTINUE TO Q5.
Q5. Patient Payment: $ ___.___
Q5a. Were there any 3rd party payers?
[IF YES, GO TO Q6. IF NO, END HERE.]
Q6. Type of 3rd Party Payer.
SOURCE: ___________
OTHER SPECIFY: _______________
Q7. 3rd Party Payment: $_____
NOTE: IF PATIENT PAYMENT WAS $1 OR LESS, EXPECT THE 3rd PARTY PAYER TO BE A PUBLIC PROGRAM, E.G., MEDICAID OR OTHER STATE/LOCAL GOVT, ETC.