Medicare Authorization Form

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Medicare Authorization Form
Please show your Medicare Card and any other insurance ID Card so we can make a copy.
I authorize the release of any medical or other information necessary to process claims for services
provided by Prairie Creek Family Medicine / Annie Jeffrey Family Medicine. I also request payment of
government funds either to myself or to Prairie Creek Family Medicine if they accept assignment.
___________________________________________________
________________________
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
DATE
Medicare Questionnaire
Medicare requires all patients to complete this questionnaire.
Patient’s Name _________________________________________________________
Current Marital Status:
Married
Single
(Never married, Widowed, Divorced)
Date of Service ____________________________________
Please check YES or NO for each question
YES
NO
1) Is the patient a veteran? If YES . . .
a) Did the VA refer you here for treatment?
b) Does the patient have a VA “fee basis ID card?”
If (a) or (b) is YES, do you authorize us to bill the VA?
2) Does the patient have a Federal Black Lung Card?
3) Is the patient covered by an employer health insurance plan
through their own employment or that of a family member?
(does not include retiree coverage)
4) Is this medical condition due to an accident of any kind?
If your answer is YES, check one box below …..
a) Work related …………………………………………………………
b) Motor vehicle ………………………………………………………..
c) Injury in your own home ……………………………………………
d) Other _____________________________________________
OFFICE USE ONLY
Provide details for any YES answers below
Group Health Plan (question 3) through:
Patient’s Employer
Spouse’s Employee
Employer
Does this employer have
Sponsoring
more than 20 employees?
Health Plan
Yes
No
Patient Account
Primary Insurance
Number
if Medicare 2nd

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