Health Services Development Agency
Medical Equipment Utilization Survey

Section 1 of 2: Contact Information and Utilization by Payer

Instructions

Thank you for using the Medical Equipment Utilization Survey online submission form. To complete the form, enter the requested data in the form below and click the "Submit Data" button. When your information has been successfully submitted, you will receive a confirmation message, a copy of the data you entered, and directions on how to proceed to Section 2 of the form.

CPT Codes can be found here: pdf icon (opens in separate window)

If you have problems or questions, call or e-mail Alecia Craighead, Staistical Analyst, at 615-253-2782, alecia.l.craighead@state.tn.us.

Note: If you have previously completed Section 1 and are returning to complete Section 2, click here to go directly to Section 2.


Contact Information
Facility Name (select from list)   
Facility Name (if not included in list)   
Facility Street Address   
Facility City/State/ZIP   
County   
Telephone Number   
Contact Person   
Contact Person's E-mail Address   
Reporting Period - From:
 Month:     Year: 
Reporting Period - To:
 Month:     Year: 



pdf icon
(opens in separate window)

Medical Equipment Data
Equipment
 # Units
 Mobile Days/Week
 Utilization
 Medicare
 TennCare/
Medicaid
 Managed Care
 Commercial
 Self-Pay/
Other
 Total
CT
Fixed Units
Procedures*:
Gross Charges*:
CT
Mobile Units		 Procedures:
Gross Charges:

Linear Accelerator
Fixed Units
Treatments:
Gross Charges:
Linear Accelerator
Mobile Units		 Treatments:
Gross Charges:

Equipment
 # Units
 Mobile Days/Week
 Utilization
 Medicare
 TennCare/
Medicaid
 Managed Care
 Commercial
 Self-Pay/
Other
 Total
Lithotripter
Fixed Units
Procedures:
Gross Charges:
Lithotripter
Mobile Units		 Procedures:
Gross Charges:

MRI
Fixed Units
Procedures:
Gross Charges:
MRI
Mobile Units		 Procedures:
Gross Charges:

Equipment
 # Units
 Mobile Days/Week
 Utilization
 Medicare
 TennCare/
Medicaid
 Managed Care
 Commercial
 Self-Pay/
Other
 Total
PET
Fixed Units
Procedures:
Gross Charges:
PET
Mobile Units		 Procedures:
Gross Charges:


 




Procedures:
Number of billing units, e.g., ICD9 or CPT4 procedures.

Gross Charges:
Charges before deductions from revenue such as contractual allowances, bad debt, and/or charity.

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