Medicare Secondary Payer Questionnaire Page 2

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Part IV
Employment Status:
1.
Does patient have current employment status? _____
if no, what was the Date of retirement?_____/_____/______
(Office use only:
If yes, provide the named and address of employer on registration screens.
If no, record the date of retirement on the occurrence code).
2.
Does patient’s spouse have current employment status? ______
if no, what was the spouse’s Date of retirement ?_____/_____/______
(Office use only:
If yes, provide the named and address of spouse’s employer on registration
screens. If no, record the spouse’s date of retirement on the occurrence code).
If no to both questions, then Medicare is primary. If health insurance exists through employment
and there are 20 or more employees, health insurance is primary.
If unable to obtain retirement date, note why?
______________________________________________________________
Part V
Disability:
Is patient RETIRED disability? _______
If yes, date of disability retirement ______/______/______
(Medicare is primary unless spouse employed with benefits)
If disability, does patient or spouse have current employment status? _______
(Office use only
: If yes, provide the named and address of employer on registration screens. If no to
employment questions, Medicare is primary. If health insurance exists, plan is primary).
Part VI
End Stage Renal Disease:
Does patient have current insurance coverage? _______
(Office use only:
).
if yes, record information on insurance screens, that plan becomes primary
Has patient received a kidney transplant? _______
If yes, date of transplant: _____/_____/______
Has patient received dialysis? _____
If yes, date dialysis began: _____/_____/______
If self dialysis, date of training: _____/_____/______
Is patient within the 30 month coordination period? _______
If yes, insurance is primary until 30 months is up.
Was patient’s initial entitlement to Medicare based on ago or disability? ______
(Office use only
.
If yes, Medicare primary. In no, insurance coverage primary until 30 months is up)
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