Medicare Secondary Payer Questionnaire
There may be situations where Medicare is not your primary payer or Medicare coverage policies vary. Medicare law requires that we investigate all possible situations where other insurance, besides Medicare, might be the primary payer.We appreciate your help by completing this questionnaire.
Patient Name
*
First Name
Middle Name
Last Name
Suffix
Account #
Are you currently receiving any Home Health Services (including nursing, bathing or dressingassistance, injections or respiratory services)?
Yes
No
Are you covered under a Medicare Part C (Medicare Advantage/ Medicare+Choice) program?
Yes
No
If yes, enter the name of the health plan
Was your illness or injury due to a work-related accident or condition?
Yes
No
If yes, enter the date of the illness or injury
Was your illness or injury due to a non-work-related accident? If no-fault, auto, or liability insurance is available, enter information in "insurance information" section below
Yes
No
If yes, enter the date of the illness or injury
If you are entitled to Medicare based upon Age or Disability, are you currently employed? If yes, provide your employers information on the "Patient Registration" form
Yes
No
Never employed
If YES, provide us with your employer’s information.
If no, enter your retirement date
Do you have a spouse who is currently employed? If YES, provide your spouse’s employer’s information on the Patient Registration.
Yes
No
Never employed
If YES, provide us with your spouse’s employer’s information.
If NO, enter your spouse’s retirement date
Do you have group health plan coverage based upon your own or your spouse’s employment? If YES, enter your and/ or your spouse’s group health plan information in "insurance information" section below
Yes
No
Are you entitled to Medicare do to End Stage Renal Disease (ESRD)? (multiple selections allowed)
Yes
No
No transplant
No dialysis
If yes, enter the date of the kidney transplant
If yes, enter the date that Dialysis began
Are you receiving Black Lung (BL) benefits?
Yes
No
If yes, enter the date that benefits began
Insurance Information
If yes to workers comp, auto, attorney or group health plan, please fill out below.
Type of coverage
Please select
Workers compensation
No-fault, auto or liability
Group health plan
Insurance name
Insurance address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance phone number
-
Area Code
Phone Number
Policy / ID#
Group #
Name of policy holder
If group health plan, approximate number of employees
Please select
1-19
20-99
100 or more
Today's date
-
Month
-
Day
Year
Date
Signature
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Submit
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