Electronic Funds Transfer (Eft) Authorization - Minnesota Department Of Revenue Page 10
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15Lines 2–5
Lines 2 through 9 —
prepaid managed-care plans for
the Migrant Health Service
services to be provided under:
Project
Amounts exempt from tax
the MA program,
county governments to provide
Line 2
the GAMC program, and
health-care services to indigent
people
Medicare and Medicare supplemental
the MinnesotaCare program
plans
the Minnesota State Soldiers
Of the total on line 1, determine the
other states for providing health-
Assistance Program
amount you received from:
care services under their Medic-
aid programs
the Minnesota Department of
Medicare for Medicare-covered
Veterans Affairs Special Relief
services
MinnesotaCare copayments and
Fund
deductible portions paid by
prepaid managed-care plans to
the Minnesota Board of Medical
patients
be applied to Medicare-covered
Practice
services
Fill in the total on line 3.
Do not include amounts received from:
Include:
the Veterans Administration
Line 4
the deductible portions and
copayments required by Medi-
Other government programs
the following insurance pro-
care for the Medicare-covered
Of the total on line 1, determine the
grams:
services, whether paid by pa-
amounts you received from any
Minnesota Comprehensive
tients and/or supplemental
government program — other than
Health Association (MCHA)
plans.
those listed on lines 2 and 3 — for
Workers Compensation
health-care services you provided.
Do not include amounts you received
Fill in the total on line 4, even if
CHAMPUS and any other
from:
you are a government agency —
health-care plan for federal
third-party insurers when
such as a regional treatment center.
government employees
Medicare is the secondary insurer
any health-care plan for
Include amounts received from:
patients or patients’ insurers for
employees of the state of
the U.S. Department of Voca-
health-care services not covered
Minnesota
tional and Rehabilitation Services
by Medicare
any health-care plan for
the U.S. Indian Health Service
employees of Minnesota local
Fill in the total on line 2.
governments
county governments using funds
Line 3
from the Minnesota Chemical
the U.S. Postal Service for
Dependency Fund
health-care services
Medical Assistance, General Assistance
Medical Care, and MinnesotaCare
the state of Minnesota for detoxi-
Fill in the total on line 4.
Of the total on line 1, include
fication services
amounts you received from:
Line 5
the state of Minnesota for reha-
the Minnesota Department of
bilitation services
Federal Employees Health Benefit Act
Human Services as fees for
Of the total on line 1, determine the
Minnesota State Services for the
health-care services you provided
amount you received under the
Blind
under:
Federal Employees Health Benefit
a federal, state or local govern-
the MA program,
Act (FEHBA). Fill in the result on
ment agency for services pro-
line 5.
the GAMC program, and
vided to prison inmates
the MinnesotaCare program
8
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial