Medicare Secondary Payor (Msp) Questionnaire - 2011 Page 2

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Brielle Orthopedics, P.A.
Medicare Secondary Payor
(MSP) Questionnaire – Page 2
IMPORTANT NOTICE TO PATIENT:
Please fill out this 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 displayed on Red-White-Blue Government Medicare Card)
Database:
5.
Have you received a kidney transplant or are currently receiving dialysis for
End Stage Renal Disease (ESRD)? ....................................................................
Yes
No
If yes, please provide the date of the transplant or start of dialysis: ____/____/____
If the date is less than 30 months ago: Are you currently covered under
group insurance provided by your or a family member’s employer?
Yes
No
If yes – the group insurance will be primary
If no – Medicare will be primary
6.
Are you currently employed?......................................................................................
Yes
No
If yes, Does your employer employ more than 20 employees?.................................
Yes
No
If no, Date of retirement:_____/_____/_____
or check  Not employed
Is your spouse currently employed?..........................................................................
Yes
No
If yes, Does his/her employer employ more than 20 employees?..............................
Yes
No
If no, Date of retirement:_____/_____/_____
or check  Not employed
(NOTE: If both are not currently employed, then Medicare is primary.)
7.
If you’ve answered No to questions 1 – 6 AND your Medicare coverage is due to
age or disability:
Do you have a group insurance plan through another family member’s current
Yes
No
employer?......................................................................................................................
If yes – the group insurance will be primary
If no – Medicare will be primary
Do you have any benefits through TriCare (formerly Champus)?...........................
Yes
No
8.
If you answered YES to questions 6 or 7, please complete the following group
insurance information for the proper billing of your account:
Insurance Co. Name:
Address:
City, State, ZIP:
Phone:
Employer Name:
Insured’s Name:
Policy Identification
(Sometimes referred to as the health
insurance benefit package number.)
Number:
Group Identification
Number:
Patient signature
Date
Appointed Representative signature
Relationship
(Page 2 of 2 – END OF QUESTIONNAIRE)
Rev. 3/2011

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