Medicare Secondary Payer Questionnaire

MEDICARE   S ECONDARY   P AYER   Q UESTIONAIRE  

There   m ay   b e   s ituations   w here   M edicare   i s   n ot   y our   p rimary   p ayer   o r   M edicare   c overage   p olicies   v ary.  

Medicare   l aw   r equires   t hat   w e   i nvestigate   a ll   p ossible   s ituations   w here   o ther   i nsurance,   b esides   M edicare,  

might   b e   t he   p rimary   p ayer.  

We   a ppreciate   y our   h elp   b y   c ompleting   t his   q uestionnaire.  

 

Patient   N ame:   _ ________________________________________             A ccount   # :   _ ___________________  

 

Responses                 S ection   I  

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_

 

 

Y es      

N o   1.     A re   y ou   c urrently   r eceiving   a ny   H ome   H ealth   S ervices   ( including   n ursing,   b athing   o r   d ressing  

assistance,   i njections   o r   r espiratory   s ervices)?  

_

_

 

 

Y es      

N o   2.     A re   y ou   c overed   u nder   a   M edicare   P art   C   ( Medicare   A dvantage/   M edicare+Choice)   p rogram?  

 

 

If   Y ES,   e nter   t he   n ame   o f   t he   h ealth   p lan:   _ ________________________  

_

_

 

 

Y es      

N o   3.     W as   y our   i llness   o r   i njury   d ue   t o   a   w ork-­‐related   a ccident   o r   c ondition?  

 

 

If   Y ES,   e nter   t he   d ate   o f   t he   i llness   o r   i njury:   _ ______________________  

_

_

 

 

Y es      

N O   4.     W as   y our   i llness   o r   i njury   d ue   t o   a   n on-­‐work-­‐related   a ccident?  

 

 

If   Y ES,   e nter   t he   d ate   o f   i llness   o r   i njury:   _ _________________________  

 

If   n o-­‐fault,   a uto,   o r   l iability   i nsurance   i s   a vailable,   e nter   i nformation   i n   S ection   I I.  

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_

 

 

Y es      

N O   5.     I f   y ou   a re   e ntitled   t o   M edicare   b ased   u pon   A ge   o r   D isability,   a re   y ou   c urrently   e mployed?  

 

__   N ever   E mployed  

 

 

If   Y ES,   p rovide   y our   e mployer’s   i nformation   o n   t he   P atient   R egistration.  

 

 

If   N O,   e nter   y our   r etirement   d ate:   _ ______________________________    

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_

 

 

Y ES      

N O   6.     D o   y ou   h ave   a   s pouse   w ho   i s   c urrently   e mployed?  

If   Y ES,   p rovide   y our   s pouse’s   e mployer’s   i nformation   o n   t he   P atient   R egistration.  

 

__   N ever   E mployed  

If   N O,   e nter   y our   s pouse’s   r etirement   d ate:   _ _______________________  

_

_

 

 

Y ES      

N O   7.     D o   y ou   h ave   g roup   h ealth   p lan   c overage   b ased   u pon   y our   o wn   o r   y our   s pouse’s   e mployment?  

If   Y ES,   e nter   y our   a nd/   o r   y our   s pouse’s   g roup   h ealth   P lan   i nformation   i n   S ection   I I.  

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_

 

 

Y ES      

N O   8.     A re   y ou   e ntitled   t o   M edicare   d ue   t o   E nd   S tage   R enal   D isease   ( ESRD)?  

 

 

 

If   Y ES,   e nter   d ate   o f   t he   k idney   t ransplant:   _ ____________________  

__   N o   t ransplant  

 

 

 

If   Y ES,   e nter   t he   d ate   t hat   D ialysis   b egan:   _ _____________________               _ _   N o   D ialysis  

_

_

 

 

Y ES      

N O   9.     A re   y ou   r eceiving   B lack   L ung   ( BL)   b enefits?    

 

 

 

If   Y ES,   e nter   t he   d ate   t hat   b enefits   b egan:   _ ____________________  

 

                        S ection   I I                         ( Please   p rovide   u s   w ith   y our   i nsurance   c ard.)  

 

_ _  

_ _

_ _

Type   o f   I nsurance   C overage:    

W orkers   C ompensation          

  N o-­‐fault,   A uto   o r   L iability        

  G roup   H ealth   P lan  

Insurance   N ame  

_____________________________________________________________  

Street   A ddress    

_____________________________________________________________  

City,   S tate,   Z ip    

_____________________________________________________________  

Phone   N umber    

_____________________________________________________________  

Policy   N umber    

_____________________________________________________________  

Group   N umber    

_____________________________________________________________  

Name   o f   P olicy   H older   _____________________________________________________________  

__  

_ _  

_ _  

If   G roup   H ealth   P lan,   a pproximate   n umber   o f   e mployees:  

  1 -­‐19                  

  2 0-­‐99              

  1 00   o r   m ore  

I   c ertify   t hat   a ll   o f   t he   i nformation   p rovided   h erein   i s   t rue   a nd   c orrect.  

 

X___________________________________________    

 

________________________  

Signature   o f   P atient/Representative      

 

 

 

Date