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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.
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 »
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Last Modified Date: November 8, 2007