Mvp Patient Information Page 7

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In order for us to comply with the Medicare as Secondary Payer laws, you must complete this form before we
can properly process your insurance claim. Please complete this questionnaire and return it to the front desk.
Do not hesitate to ask for clarification for any item on this form.
1.
I am working full-time ____ part-time ____. I retired on ___/___/______.
2. A. I had a job-related injury on ____/_____/_______.
B. I had an organ transplant on _____/_____/_______.
C. I have been on kidney dialysis since ____/_____/_______.
D. I am being treated for an injury received in a car accident which occurred on___/_____/________.
Other vehicle (please identify):__________________________________
E. Other type of accident (Date and Place where the accident occurred):
____/____/______
3.
PLEASE CIRCLE YES OR NO.
A. I am entitled to Black Lung Benefits.
NO
YES
B. I have a fee service card from the VA.
NO
YES
C.
I am covered by Medicaid.
NO
YES If YES, ID #: ________________________
4. TO ALL STATEMENTS BELOW THAT APPLY TO YOU:
CIRCLE YES OR NO
A. I am enrolled in a Medicare HMO plan.
NO
YES
B. I/My Spouse has purchased a private insurance policy to supplement Medicare.
NO
YES
C. I have health insurance through my/my spouse’s previous employer or union.
NO
YES
D. I am retired and covered by an employer-sponsored retiree health plan.
NO
YES
E. I am retired, but have been called back temporarily and have employee health
NO
YES
benefits while I am working.
F. I/My spouse is employed and I am covered by an employer-sponsored health
NO
YES
care program covering more than 20 employees
If you circled YES to any of the statements in question 4: Name of Plan: ____________________________________
Subscriber/ID #: ____________________________ Name of Subscriber: ____________________________________
I certify that the answers above are true to the best of my knowledge. I will notify MVP Physical Therapy to any
changes to my coverage during my treatment.
_____________________________________________________________
Date: ____________________________
(Patient or Representative Signature)
_____________________________________________________________
DOB: ________/_______/____________
(Please Print Patient Name)
Medicare Paperwork
ALL INFORMATION ON THIS FORM IS CONFIDENTIAL
01/2015

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