MEPS-HC Survey Instrument

PATIENT LABEL

GLOBAL FEE CONTINUATION SHEET
FOR
HOSPITALS FOR REFERENCE YEAR 2005

M:\7690\7690.19.04\MPC 2005\Forms\HOSP\Hosp B2b ContSheet.doc - 1/26/2006 - 11:41 AM - LA

B2b. What other dates of service were covered by this global
fee? Please include dates before or after 2005 if they
were included in the global fee.

MO DAY
YR
TYPE
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____/____/______ _____
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IF TYPE 96, SPECIFY:
|__|__|
OFFICE
USE
ONLY

B2c. Did (PATIENT NAME) receive the services on (DATE)
in a:
Physician's Office (TYPE=MV);
Hospital as an Inpatient (TYPE=SH);
Hospital Outpatient Department (TYPE=SO);
Hospital Emergency Room (TYPE=SE); or
Somewhere else (TYPE=96)?