Medicare Secondary Payer Form - Form A-1

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Medicare Secondary Payer Form
DATE___________________
PATIENT NAME____________________________________
Dear Medicare Patient:
As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the
following information to determine if Medicare is your primary insurance.
□
□
1.
Is the illness/injury due to an automobile accident, liability accident or Workman’s Compensation?
Yes
No
□
□
2.
Is illness covered by the Black Lung Program or Veterans Administration program?
Yes
No
□
□
3.
If under 65, are you a renal dialysis patient in your first 30 months of Medicare entitlement?
Yes
No
□
□
4a. If under age 65, is your Medicare coverage due to disability?
Yes
No
□
□
4b. Is patient covered by a large group health plan through patient’s employer or spouse’s
Yes
No
current employer?
□
□
5.
If 65 and over, is patient covered by Employer Group Health Plan through patient’s or spouse’s
Yes
No
current employer?
Registrar Notes:
A. If patient responds “no” to questions 1-5, Medicare is primary.
B. If patient responds “yes” to any questions, Medicare is secondary and primary insurance information must be
obtained.
Name of Insurance Company ____________________________________________________________________
Address of Insurance Company __________________________________________________________________
__________________________________________________________________
Name of Policy Holder _________________________________________________________________________
Policy Number _______________________________________________________________________________
Policy Holder’s Employer Name __________________________________________________________________
Policy Holder’s Employer Address ________________________________________________________________
Date of Accident (if applicable) ___________________________________________________________________
Patient’s Signature ___________________________________________
Form A-1

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