MEDICARE
S ECONDARY
P AYER
Q UESTIONAIRE
There
m ay
b e
s ituations
w here
M edicare
i s
n ot
y our
p rimary
p ayer
o r
M edicare
c overage
p olicies
v ary.
Medicare
l aw
r equires
t hat
w e
i nvestigate
a ll
p ossible
s ituations
w here
o ther
i nsurance,
b esides
M edicare,
might
b e
t he
p rimary
p ayer.
We
a ppreciate
y our
h elp
b y
c ompleting
t his
q uestionnaire.
Patient
N ame:
_ ________________________________________
A ccount
# :
_ ___________________
Responses
S ection
I
_
_
Y es
N o
1.
A re
y ou
c urrently
r eceiving
a ny
H ome
H ealth
S ervices
( including
n ursing,
b athing
o r
d ressing
assistance,
i njections
o r
r espiratory
s ervices)?
_
_
Y es
N o
2.
A re
y ou
c overed
u nder
a
M edicare
P art
C
( Medicare
A dvantage/
M edicare+Choice)
p rogram?
If
Y ES,
e nter
t he
n ame
o f
t he
h ealth
p lan:
_ ________________________
_
_
Y es
N o
3.
W as
y our
i llness
o r
i njury
d ue
t o
a
w ork-‐related
a ccident
o r
c ondition?
If
Y ES,
e nter
t he
d ate
o f
t he
i llness
o r
i njury:
_ ______________________
_
_
Y es
N O
4.
W as
y our
i llness
o r
i njury
d ue
t o
a
n on-‐work-‐related
a ccident?
If
Y ES,
e nter
t he
d ate
o f
i llness
o r
i njury:
_ _________________________
If
n o-‐fault,
a uto,
o r
l iability
i nsurance
i s
a vailable,
e nter
i nformation
i n
S ection
I I.
_
_
Y es
N O
5.
I f
y ou
a re
e ntitled
t o
M edicare
b ased
u pon
A ge
o r
D isability,
a re
y ou
c urrently
e mployed?
__
N ever
E mployed
If
Y ES,
p rovide
y our
e mployer’s
i nformation
o n
t he
P atient
R egistration.
If
N O,
e nter
y our
r etirement
d ate:
_ ______________________________
_
_
Y ES
N O
6.
D o
y ou
h ave
a
s pouse
w ho
i s
c urrently
e mployed?
If
Y ES,
p rovide
y our
s pouse’s
e mployer’s
i nformation
o n
t he
P atient
R egistration.
__
N ever
E mployed
If
N O,
e nter
y our
s pouse’s
r etirement
d ate:
_ _______________________
_
_
Y ES
N O
7.
D o
y ou
h ave
g roup
h ealth
p lan
c overage
b ased
u pon
y our
o wn
o r
y our
s pouse’s
e mployment?
If
Y ES,
e nter
y our
a nd/
o r
y our
s pouse’s
g roup
h ealth
P lan
i nformation
i n
S ection
I I.
_
_
Y ES
N O
8.
A re
y ou
e ntitled
t o
M edicare
d ue
t o
E nd
S tage
R enal
D isease
( ESRD)?
If
Y ES,
e nter
d ate
o f
t he
k idney
t ransplant:
_ ____________________
__
N o
t ransplant
If
Y ES,
e nter
t he
d ate
t hat
D ialysis
b egan:
_ _____________________
_ _
N o
D ialysis
_
_
Y ES
N O
9.
A re
y ou
r eceiving
B lack
L ung
( BL)
b enefits?
If
Y ES,
e nter
t he
d ate
t hat
b enefits
b egan:
_ ____________________
S ection
I I
( Please
p rovide
u s
w ith
y our
i nsurance
c ard.)
_ _
_ _
_ _
Type
o f
I nsurance
C overage:
W orkers
C ompensation
N o-‐fault,
A uto
o r
L iability
G roup
H ealth
P lan
Insurance
N ame
_____________________________________________________________
Street
A ddress
_____________________________________________________________
City,
S tate,
Z ip
_____________________________________________________________
Phone
N umber
_____________________________________________________________
Policy
N umber
_____________________________________________________________
Group
N umber
_____________________________________________________________
Name
o f
P olicy
H older
_____________________________________________________________
__
_ _
_ _
If
G roup
H ealth
P lan,
a pproximate
n umber
o f
e mployees:
1 -‐19
2 0-‐99
1 00
o r
m ore
I
c ertify
t hat
a ll
o f
t he
i nformation
p rovided
h erein
i s
t rue
a nd
c orrect.
X___________________________________________
________________________
Signature
o f
P atient/Representative
Date