Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception printable pdf download

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

Instructions:

1. Please read the information in the letter accompanying this form.

2. Complete all questions; fill in all blanks.

3. Return this completed form, along with the MSP Cover Letter on letterhead (see next two pages), to

Banyan Administrators, LLC via:

Toll-Free FAX: (877) 237-4519

<OR>

Scan and email:

Name of Employer:

__________________________

Employer Address:

__________________________

Tax or Employer ID No: ______________

1. Did your company have 20 or more full-time and/or part-time employees on the payroll for 20 or

more weeks (consecutive or non-consecutive) at any time during this calendar year?

_____ Yes

_____ No

2. Did your company have 20 or more full-time and/or part-time employees on the payroll for 20 or

more weeks (consecutive or non-consecutive) at any time during the preceding calendar year?

_____ Yes

_____ No

3. What is the current number of employees on your payroll? _________

4. If the answers to both (1) and (2) above are “No,” please verify and/or complete the list below,

including the Health Insurance Claim Number (or Social Security Number) for each employee

who is 65 years or older, and his/her spouse.

Please add information on any employees/spouses at or over the age of 65.

Name

SSN

Date of Birth

HIC Number

I understand that the Group Insurance Trust of the California Society of CPAs is relying on my

answers to the above questions to determine whether Medicare will be the primary payer of claims

for my Medicare eligible employees. I affirm that the answers are true to the best of my knowledge

and belief. I also understand that I am responsible to promptly notify the Group Insurance Trust of

the California Society of CPAs if my answers to the above questions change during the course of my

plan year because I have gained or lost employees.

Authorized Signature

Please Print Name

Date

1215 Manor Drive, Suite 200 | Mechanicsburg, PA 17055 | Phone 877.480.7923 | Fax 877.237.4519

Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception