MEPS-MPC-Hospital

Medical Provider Component
M E D I C A L

E X P E N D I T U R E

P A N E L

S U R V E Y

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OMB # 0935-0108

Provider ID/W
Provider Name

Customer List
The customers listed below have given authorization to contact you and request information
from their records. Copies of the signed authorization forms are attached.
Each customer’s name, date of birth, and gender are provided to help you to locate the
customer in your records.
For each customer, we will be asking about prescriptions received between January 1, 2005
and December 31, 2005. For each prescription we will need the date filled, the NDC code,
quantity dispensed, charges and payments.
A data collection coordinator will be calling you shortly after you have received these materials
to collect the information over the telephone.

Customer Name
1
2
3
4
5

Date of Birth

Sex