Medicare & Elder Maltreatment Patient Questionnaire
The following questions are a legal requirement for Premier Rehabilitation to have completed in order to meet Medicare Guidelines. This form is required for Medicare and Medicare Supplement Programs. Please answer all questions to the best of your knowledge. Do not leave any questions blank as this may result in Medicare denying payment.
Name
*
First Name
Last Name
Are you entitled to Medicare based on:
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Age
Disability
End Stage Renal Disease (ESRD)
I am not entitled to Medicare
Are you currently employed?
*
Yes
No
Yes: Employer name, address, phone number
No: Retirement date (Specific date if known, otherwise please list the year of retirement)
Do you have health insurance based upon your own or your spouse’s current employment?
*
Yes
No
Are you receiving Black Lung Benefits?
*
Yes
No
Was your injury/illness caused by an automobile accident?
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Yes
No
If Yes, what is your Insurance Company, address, claim number, adjuster:
Was your injury/illness caused by accident other than an automobile accident?
*
Yes
No
If Yes, is another party responsible for your medical bills? Please explain:
Elder Abuse Suspicion Index
*
Yes
No
Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with?
Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
Has anyone tried to force you to sign papers or to use your money against your will?
Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
Today's Date
*
-
Month
-
Day
Year
Date
Patient Signature
*
Submit Form
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