Medicare Questionnaire Template printable pdf download

Medicare Questionnaire Template

Great Basin Physical Therapy and

Performance Center

Medicare Questionaire

To assist with our Medicare billing, we need the following information:

1. Did you receive Home Health Care within the past year? ( ) yes ( ) no

(Home Health Care is defined as anyone coming to your home doing

therapy, cleaning, taking blood pressure, etc. from a health care agency).

a) If yes, please list the name of the company who supplied the home

health or the name of therapist who assisted you:

____________________________________________________________

b) Date Medicare released you from Home Health:_______________

STOP: If you answered yes to the above question, Medicare must release you

from Home Health in order to be seen in our office. Medicare will not pay for

Home Health & Outpatient Physical Therapy at the same time.

2. Were you admitted to a Rehabilitation Center within the past year?

( ) yes ( ) no

If yes, which center were you admitted?

_____________________________________________________________

a) What date were you discharged?_________________________________

STOP: You must have been discharged from the Rehabilitation Center in order to

be seen in our office.

3. Have you been hospitalized within the past year with this problem? If yes,

when were you discharged from the hospital & which hospital were you

in:___________________________________________________________

4. When is your next Doctor’s appointment?____________________________

__________________________________________

____________________

Patient Signature or Representative

Date

Thank you for your assistance,

Great Basin Physical Therapy and Performance Center, LLC.

Medicare Questionnaire Template