Mandatory Second Payer (Msp) Form
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1
2Health Reimbursement Account (HRA)
Mandatory Second Payer (MSP) Form
Mandatory reporting requirements apply to all HRA participants and their dependents as a result of Section 111 of the Medicare, Medicaid
and SCHIP Extension Act of 2007. These Mandatory Second Payer (MSP) rules ensure that Medicare does not pay for medical claims that
should first be paid by another source and are designed to identify which entity is the primary payer. You are required to complete this form.
If you do not have any dependents, only complete the “Your Information” section. If you are not eligible for, or currently participating in, a
Medicare related program, you must still report basic information for yourself and each of your dependents. Dependents are the
individual claimed on your Federal Tax Return (examples: spouse, children, etc.) Please complete a second form to report additional
dependents. Call Capital Financial Group Inc at (518) 793-2885 or (888) 793-2999 with questions. Please see sending instructions below.
Your Information (Please print clearly)
SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Are you eligible for Medicare?
Yes
No
If yes, complete the questions below:
Name: ______________________________________
Are you disabled?
Yes
No
Address: _____________________________________
If yes, provide Disable date:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________
Are you in End-Stage Renal Disease?
Yes
No
____________________________________
If yes, provide End-Stage Date:
Date of Birth: ___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Gender:
Male
Female
Medicare Claim #:___ ___ ___ - ___ ___ - ___ ___ ___ ___ - ___
Your Dependent #1 (Please print clearly)
SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Are you eligible for Medicare?
Yes
No
If yes, complete the questions below:
Name: ______________________________________
Are you disabled?
Yes
No
Address: _____________________________________
If yes, provide Disable date:
___ ___ / ___ ___ / ___ ___ ___ ___
____________________________________
Are you in End-Stage Renal Disease?
Yes
No
____________________________________
If yes, provide End-Stage Date:
Date of Birth: ___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Gender:
Male
Female
Medicare Claim #:___ ___ ___ - ___ ___ - ___ ___ ___ ___ - ___
Relationship to you: ___________________________
By submitting this form, I certify that the information listed below is accurate to the best of my knowledge. I understand that this information
is required to accurately coordinate benefits with Medicare and to meet mandatory reporting obligations.
Signed: ________________________________________________________
Date: ___________________________________________
Employer Group: __________________________________________________________________________________________________
Sending Instructions:
Mail to: Capital Financial Group, Inc.
89 Saratoga Avenue
South Glens Falls, NY 12803
Side 1
Fax to: (518) 798-7502
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