Attachment 90 – MPC Separately Billing Doctor Provider Overflow Patient List

OMB#: 0935-0118

Medical Expenditure Panel Survey – Medical Provider Component

Reference #: «GID»

Confidential Patient Checklist – (Continued)
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Attachment 90 – MPC SBD Overflow Patient List

						CHECK ONE FOR EACH PATIENT
Provider Name	Provider Specialty	Hospital Name	Patient Name	Date of Birth	Gender	2017 Records Located	2017 Records NOT Located