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By payments I mean any expenses paid by any members of your CU directly to a medical provider by cash, check, credit card, or automatically deducted from your account for a medical service or item. Include all payments, even those for persons who are outside of your CU.
For definitions Information Booklet »
Since the first of the reference month, have you or any members of your CU made any payments for the following?
* Read each item on list
Describe the care/service/item.[enter text] _______________
Who was/were the "care/service/item" for?
* Enter name of person: [enter text] _____________
In what month was(were) the payment(s) made? [enter text] _____________
* Enter 13 for a continuous expense
What was the total amount paid in the above month?/ Enter monthly amount if continuous. [enter value] _____________
* Enter 'C' for a combined expense
What is the "care/service/item" combined with?
* Enter all that apply
Did you or any members of your CU make any other payments for the "care/service/item"?
Go to Section 15 Part B - Screening Questions for Reimbursements »
Go to CE CAPI Survey Instrument Home Page »
Last Modified Date: November 8, 2007