Medicare Secondary Payer Questionnaire (Short Form)

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Silicon Valley Surgery Center
14601 South Bascom Avenue, Suite 100
Los Gatos, CA 95032
408.402.0663
Medicare Secondary Payer Questionnaire
(Short Form)
1. Are you receiving benefits from any of the following programs?
Black Lung
____No ____Yes
Research Grant
____No ____Yes
Veteran Affairs
____No ____Yes
2. Was the illness/injury due to a work related accident/condition?
_____ No
_____ Yes
Date of injury/illness: __________________
3. Was illness/injury due to a non-work related accident?
_____ No
_____ Yes
Date of accident: ___________________
What type of accident caused the illness/injury?
_____ Automobile _____ Non-automobile
4. Are you entitled to Medicare based on:
_____ Age
_____ Disability
_____ End Stage Renal Disease
5. Are you currently employed?
_____ No
_____ Yes
6. Is your spouse currently employed?
_____ No
_____ Yes
7. Do you have health insurance sponsored through your own or spouse’s employer?
_____ No
_____ Yes
8. Does the employer that sponsors your insurance plan employ 20 or more employees?
_____ No
_____ Yes
9. Are you currently a patient in a skilled nursing facility such as a nursing home?
(Long form not required. ALERT: If yes, bill SNF not Medicare)
_____No
_____ Yes
I confirm that the above information is correct.
Patient Signature:_______________________________
Please Print Name:______________________________

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