hosp

[p. 54]

HOSPITAL PAGE

We are also collecting information on hospital and surgical costs. Before I ask the next questions, it would be helpful if you would get the hospital bills and any surgeon's bills for the hospital stay(s) you told me about for --,--, etc. (and the doctor's bill for -- delivery.)

1. Person number ____
Probe
I.C. or Dum.

You said that -- was in the hospital (nursing home) during the past year -
2. When did -- enter the hospital (nursing home) (the last time)?
USE YOUR CALENDAR
Make sure the YEAR is correct

3. What is the name and address of this hospital (nursing home)?

4. How many nights was -- in the hospital (nursing home)?

5a. How many of these -- nights were during the past 12 months?

b. How many of these -- nights were during the past 2 weeks?

c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?

If medical name unknown, enter an adequate description.
Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.
6. For what condition did -- enter the hospital (nursing home) -- do you know the medical name?

Ask for all conditions EXCEPT deliveries and births.

7. Was this the first time -- was hospitalized for -- ?

If name of operation is not known, describe what was done.
8a. Were any operations performed on -- during this stay in the hospital (nursing home)?

b. What was the name of the operation? If name of operation is not known, describe what was done. ________

c. Any other operations?

ITEM T
Mark appropriate box(es):

b. What kind of place did -- go to? (Specify)
Interviewer: If place in 9b is a hospital, nursing home, or similar place, was a Hospital page filled for that stay?

10. After leaving the hospital (nursing home) how many days did -- have to remain in bed all or most of the day?

11. ALTOGETHER how many days was -- confirmed to the house after returning home from the hospital (nursing home)?

Enter the person number and date of entry
12. Ask questions 13 through 18 for each completed hospitalization

13. What was the total amount of the hospital bill for this stay?
Do not include any doctor's or surgeon's bills.
Mark one box

14a. Did (will) health insurance pay any part of the hospital bill?

b. What is the name of the insurance plan?

c. Did (will) any other health insurance plan pay part of this hospital bill?

Ask for each health insurance plan named, then go to 15b.
d. What was (will be) the amount paid by (name of plan)?

Enter total amount paid by health insurance in line A.
Enter any amount paid by Social Security Medicare in line B.
15a. Who paid (will pay) the hospital bill?

b. Did (you or) any other person or agency pay any other part of the hospital bill?

c. Who was this?

d. What was the amount paid by --?

INTERVIEWER CHECK ITEM

b. Is the $______ for the surgeon's (doctor's) bill included in the $______ amount you gave for the hospital bill?

17a. Did (will) health insurance pay any part of the surgeon's (doctor's) bill?

b. What is the name of the insurance plan?

c. Did (will) any other health insurance plan pay part of the surgeon's (doctor's) bill?

Ask for each health insurance plan named, then go to 18b.
d. What was (will be) the amount paid by (name of plan)?

Enter total amount paid by health insurance in line A
Enter any amount paid by Social Security Medicare in line B
18a. Who paid (will pay) the surgeon's (doctor's) bill?

b. Did (you or) any other person or agency pay any other part of the surgeon's (doctor's) bill?

c. Who was this?

d. What was the amount paid by --?

19. NOTE: If the condition in Q.6 or 8 is on Card D, or there are "1" or more nights in Q.5b, a Condition page is required.
If there is no Condition page, fill one after completing all required Hospital pages.