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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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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