Medicare Secondary Payor (Msp) Questionnaire - 2011

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Brielle Orthopedics, P.A.
Medicare Secondary Payor
PSS Name:
(MSP) Questionnaire – Page 1
___________________________________________
Facility
Phone:_________________________________________
Person Contacted @ HHA:
IMPORTANT NOTICE TO PATIENT: Please fill out this
Name: ___________________________
form in its entirety. Failure to do so may result in a delay in obtaining your Medicare benefits.
Office use only
Patient Name:
Clinic Name:
Medicare Number:
Patient Acct#:
(exactly as appears- Red-White-Blue Government Medicare Card)
Database:
1. Have you received Home Health Care of any kind in the past 60 days or
currently are residing in a Skilled Nursing Facility? ................................................
Yes
No
Agency Name/Facility Name: _____________________________________
Phone: _______________________
If in a Skilled Nursing Facility: Are you on/in the “Medicare Unit”?
Yes
No
2. Are you entitled to benefits under the Black Lung Program, Dept. of Veteran
Affairs or other government program?.......................................................................
Yes
No
If yes, Program Name:_______________________ Phone: _________________
Address, City, State, ZIP:
__________________________________________________________________________________
NOTE: The government program listed in question #2 will be primary to Medicare.
3. Was this injury/illness due to any of the following?
Work-related? If yes, date of accident/injury: ________ /_______ /_________......
Yes
No
Auto accident? If yes, date of accident: ________ /_______ /_________..............
Yes
No
Accident on Property? (other than your own)(Example: store, restaurant, etc.) .....
Yes
No
If yes, date of accident: _______ /______ /_______
If yes, please give details of the accident:
If yes, please provide the following information about the liability insurance:
Insurance Name:________________________ Phone: ____________________
Address, City, State, ZIP:
__________________________________________________________________________________
Contact Person/Adjustor’s Name: _______________________________________
Claim Number: ___________________________
(required)
NOTE: Medicare regulations require us to file with the above liability insurance first, even if they will
not pay directly or immediately. We must comply with this regulation before filing with Medicare. Your
understanding and cooperation is appreciated.
4. Do you feel you have a right to be compensated by a party who may have
caused the injury or illness?........................................................................................
Yes
No
If yes, do you intend to file a liability claim or lawsuit in connection with this injury
or illness?....................................................................................................................
Yes
No
If yes, Attorney’s Name: ____________________________________________
Law Firm Name: __________________________________________________
Address: ________________________________________________________
Phone number: ___________________________________________________
(Page 1 of 2 – Go to Page 2)
Rev. 3/2011

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