2. When did -- enter the hospital (nursing home) (the last time)?
USE YOUR CALENDAR
Make sure the YEAR is correct
Year 19 _ _
City (or county) ____
Complete question 5 from entries in questions 2 and 4; if not clear, ask the questions.
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)?
For delivery, ask: Was this a normal delivery?
For newborn, ask: Was the baby normal at birth?
If "No," ask: What was the matter?
Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.
 Normal at birth
Part of body ____
0  N (8)
b. What was the name of the operation? If name of operation is not known, describe what was done. ________
c. Any other operations during this stay?
2. Social Security Medicare
3. Hospital insurance or Doctor Visit insurance
4. Workmen's compensation
5. Accident insurance carried by family or someone outside the family
6. Armed Forces Dependent Care (CHAMPUS)
7. Veteran's Benefits
10. Other (Some other source)
8a. Which of these sources paid or will pay any of this hospital bill?
 10 (Specify) ____
2 N (d)
c. Which source?
Circle additional sources in 8a. Reask 8b and c
 "1" is not circled in 8a (d)
2  N (f)
f. What part of the hospital bill was or will be paid by hospital insurance, less than half or on half or more?
2  1/2 or more
g. Did or will hospital insurance pay all of the hospital bill?
2  N
9. NOTE: If the condition in Q. 6 or 7 is in Q. 38 or 39 or there is "1" or more nights in Q. 5b, a Condition page is required. If there is no Condition page, fill one after completing columns for all required hospitalizations.