Medicare Secondary Payer Questionnaire Federal Law Requires Completion Of This Form For All Medicare Patients

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Medicare Secondary Payer Questionnaire
Federal law requires completion of this form for all Medicare patients
Name (First, MI, Last):__________________________ Date of Birth: _________ Date of Service: _________
1. Is the patient 65 years or older? Yes____ or No ____
2. Is the patient currently employed? Yes ___ or No_____
If yes, current employer name_______________________________________________________
Employer address________________________________City _____________ State _______ Zip _______
2b. Does this employer employ 20 or more employees? Yes ____ or No ____
2c. Does the patient have an insurance health plan through this current employer? Yes ___ or No ___
If Yes: Insurance company name ______________________________________
Insurance address ________________________________ City _____________ State _______ Zip ______
Policy #: ______________________________________________
2d. If not currently employed: Has the patient ever worked? Yes ___ No ___
If Yes, date last worked: _________
3. Is the patient married? Yes _____ No _____ If no, go on to question 4a
3a. If yes, is spouse currently employed? Yes ___ No___
3b. If yes, spouse’s employer name__________________________________________
Employer address ______________________________ City ______________State ________ Zip _____
3c. Does this employer employ 20 or more employees? Yes ___ or No ____
3d. Is the patient covered by an insurance health plan through this employer? Yes ____ or No ____
If yes, Insurance company name ______________________________________
Insurance address ______________________________ City ______________ State _______ Zip ______
Policy #: ______________________________________________
3e. If spouse is not currently employed: Has the spouse ever worked? Yes ___ No ___
If Yes, date last worked: ___________
4a. Is the patient entitled to Medicare solely on the basis of disability other than ESRD? Yes __ or No__
4b. Is the patient covered by an Insurance Group Health Plan through the current employment of someone
other than self or spouse? Yes ____ or No ____
4c. If yes, employer name_________________________________
Employer address ______________________________ City ______________State ________ Zip ______
4d. Subscriber name ________________________________ relationship to patient ____________________
Insurance company name __________________________________ Policy # ________________________
Insurance address _______________________________ City _____________ State _______ Zip ______
MSP questionnaire2.doc
Rev 06/07/07

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