Medicare Secondary Payer Questionnaire printable pdf download

Medicare Secondary Payer Questionnaire

MEDICARE SECONDARY PAYER QUESTIONNAIRE

In compliance with Federal Law, our office will verify all data below by using the questions found in

§20.1 to help identify other payers that may be primary to Medicare. Our providers will comply with any

instructions that follow a particular question.

Today’s Date: _________

Patient’s Name: ____________________________ DOB: ___________

1. Are you currently residing in a skilled nursing home?

If yes, name and address of the facility________________

___________________________________________.

Yes

2. Does the patient have Medicare coverage because of age?

Yes

3. Is the patient retired? Date of Retirement ________________

Yes

4. Does the patient have Medicare coverage because of a disability?

Yes

A. Does the patient have Medicare because of End Stage Renal Disease?

Yes

B. Has this patient completed the ESRD coordination waiting period?

Yes

5. Is the patient or spouse employed?

Yes

Who is employed? Patient

Patient’s Spouse

Both

Neither

6. Does the above employer have 20 or more employees?

Yes

7. Is the patient covered by Insurance through the above job?

Yes

8. Does Worker’s Compensation cover today’s illness/injury?

Yes

If yes, date of injury ___________

* If you answered YES to questions 4-6 Medicare is your secondary payer. Please provide our office staff

with your primary payer’s billing information.

Medicare Secondary Payer Questionnaire