Attachment 101 – MPC Pharmacy Provider Overflow Patient List

OMB#: 0935-0118

Medical Expenditure Panel Survey – Medical Provider Component

Reference #:

Confidential Customer Checklist – (Continued)
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Attachment 101 MPC Pharmacy Overflow Patient List

Provider Name		Customer Name	Customer Address	Date of Birth	Sex M/F	2017 Rx Found	Cust Found No 2017 RX	Not a Cust