Medicare Secondary Payer Screening Form Page 2

ADVERTISEMENT

Medicare Secondary Payer Screening Form




[A] Patient is covered under a Group Health Plan:
[B] Automobile/Medical or any Liability Screening
Employer Information is for:
If Medicare is to be billed Explain accident and why
€ Patient € Spouse € Other:____________
Medicare is still primary:
________________________________________
Employer Name:_____________________
________________________________________
Address:______________________________
________________________________________
_____________________________________
________________________________________
City, State, Zip________________________
If Medicare is not payer Please complete:
Insurance company::_____________________
Date of injury:_____ _____ _____
Policy/Group No.:_____________________
Automobile (Complete A)
Third Party Liability (Complete B
Premise Medical Coverage (Complete A
Insured’s Name_______________________
Work related (Complete C)
Address:_____________________________
___________________________________
1. Automobile Medical/Premise Medical
City, State, Zip________________________
(if 3rd party liability also exists complete A and B)
[C] Work Related – Worker’s compensation is
Automobile medical insurance/Premise medical
the primary payer.
insurance is the primary payer. Bill auto-medical or no-
fault insurance first.
Please complete the following if a Worker’s
Insured’s Name_________________________________
Compensation claim has been filed.
Policy Number_________________________
Injury or illness______________________
Insurance Company________________________
Name of Carrier______________________
Address_________________________________
Address____________________________
Description of Accident (see box__)
Employer____________________________
2. Third Party Liability (other than auto/medical,
Case/File Number___________
premise medical or work related)
For A/B & C complete the following:
Description of
B. Bill third party payer or Medicare conditionally after 120
Accident________________________
days.
Description of Accident (see box__)
__________________________________
Location* If accident occurred at a location other than
__________________________________
patient’s residence, please provide
__________________________________
information even if liability is in question.
__________________________________
[D] coordination periods for ESRD
Name of responsible party_________________
1. Did the coordination period begin 3/96 or
Policy Number_____________
after? If yes Medicare is secondary for 30
Insurance Address__________________________
months
Insurance Claim Number____________
2. Did the coordination period begin 2/96 or
Attorney Name________________________ Telephone
before? If yes Medicare is secondary for 18
Number______________
months.
Attorney Address_________________________
Date of Kidney transplant /home Dialysis
[E] Patient entitled to Medicare due to age or disability
_ _/_ _ /_ _ (3 month waiting period does not
and ESRD (Dual entitlement)
apply) If participating in self dialysis training
program what is start date _ _/_ _/_ _
this is true based on # 7 & D _________ patient initials
Patient
signature



























































clinician
signature



HIC Number________________ Patient Name___________________________________
secondaryMedicarescreening
022211




ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medicare Secondary Payer Screening Form Medicare Secondary Payer Screening Form Medical
Medicare Secondary Payer Change Form Medicare Secondary Payer Change Form Medical
Medicare Secondary Payer Questionnaire Form Medicare Secondary Payer Questionnaire Form Life
Medicare Secondary Payer Questionnaire Federal Law Requires Completion Of This Form For All Medicare Patients Medicare Secondary Payer Questionnaire Federal Law Requires Completion Of This Form For All Medicare Patients Medical
Medicare Secondary Payer Questionnaire (short Form) Medicare Secondary Payer Questionnaire (short Form) Medical
Medicare Secondary Payer Form - Form A-1 Medicare Secondary Payer Form - Form A-1 Medical
Form Cms-1563 - Monthly Intermediary Report On Medicare Secondary Payer Savings Form Cms-1563 - Monthly Intermediary Report On Medicare Secondary Payer Savings Medical
Form Cms-1564 - Monthly Carrier Report On Medicare Secondary Payer Savings Form Cms-1564 - Monthly Carrier Report On Medicare Secondary Payer Savings Medical
Medicare Secondary Payer - Auditing And Monitoring Program Medicare Secondary Payer - Auditing And Monitoring Program Medical
Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2