Medicare Secondary Payer Questionnaire for Agility Physical Therapy

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
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
Today's date

Month Day Year
Date
Signature

Clear
Should be Empty:

Medicare Secondary Payer Questionnaire

Insurance Information