Medicare Secondary Payer Questionnaire

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MEDICARE SECONDARY PAYER QUESTIONNAIRE
Person Giving Information: ______________ Relationship to Patient:__________________
Patient Name: _____________________________________________________________
HIC Number: ______________________________________________________________
Patient Age__________________________ Patient Sex ___________________________
Basis for Patient Entitlement to Medicare
________ Age________ Disability
__________ End Stage Renal Disease (ESRD)
________________________________________________________________________
Group Health Plan Information
1. Is the patient or patient’s spouse currently employed?
_______ Yes _______ No
If No:
Retirement date of patient: _______________________
Retirement date of spouse: _______________________
If Yes, continue.
Is patient or spouse employed?
___________________________________________
Are there:
__________ 1. Less than 20 employees
__________ 2. More than 100 employees
Is employee actively working?
________ Yes
________ No
Insurance Company:_____________________________________________________
Policy Number: _________________________Claim Number: ___________________
Insurance Plan Name: ___________________________________________________
Plan Identification Number: _______________________________________________
Is the patient employed? ____ Yes ____ No
Full Time? ______ Part Time?______
Employer Name: _______________________________________________________
Employer Address: _____________________________________________________
City ___________________________ State ________
Zip Code _____________
Employer Identification Number: ___________________________________________
______________________________________________________________________
Automobile, No Fault or Liability Insurance Information
2.
Is the illness/injury due to an accident (auto included)? _____ Yes _____ No
If Yes, continue.
Type of non-work-related accident: ______ Automobile
______ Other (describe) ______
Date of Accident: ________________________
Insurance Situation: ___________ Liable
___________ Not Liable
Name of Policy Holder: ___________________________________________________
Address of Policy Holder: __________________________________________________
Policy Number or Claim identification Number: _________________________________
Name of Insurance Company: ______________________________________________
Address of Insurance Company: ____________________________________________
Name of Patient’s Legal Representative for the case if any: _______________________
Phone Number of Legal Representative: ______________________________________

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