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Medicare Secondary Payer Questionnaire - medicare msp questionnaire printable


Medicare Secondary Payer Questionnaire-medicare msp questionnaire printable

Attachment B1.003D Page 1 of 2
MEDICARE SECONDARY PAYER QUESTIONNAIRE
Person Giving Information: Relationship to Patient:
Patient Name:
HIC Number:
Patient Age Patient Sex
Basis for Patient Entitlement to Medicare
Age Disability End Stage Renal Disease (ESRD)
Group Health Plan Information
1. Is the patient or patient's spouse currently employed? Yes No
If No: Retirement date of patient:
Retirement date of spouse:
If Yes, continue.
Is patient or spouse employed?
Are there: 1. Less than 20 employees
2. More than 100 employees
Is employee actively working? Yes No
Insurance Company:
Policy Number: Claim Number:
Insurance Plan Name:
Plan Identification Number:
Is the patient employed? Yes No Full Time? Part Time?
Employer Name:
Employer Address:
City State Zip Code
Employer Identification Number:
Automobile, No Fault or Liability Insurance Information
2. Is the illness/injury due to an accident (auto included)? Yes No
If Yes, continue.
Type of non-work-related accident: Automobile Other (describe)
Date of Accident:
Insurance Situation: Liable Not Liable
Name of Policy Holder:
Address of Policy Holder:
Policy Number or Claim identification Number:
Name of Insurance Company:
Address of Insurance Company:
Name of Patient's Legal Representative for the case if any:
Phone Number of Legal Representative:
? 2003 U.S. Physical Therapy, Inc.
Attachment B1.003D Page 1 of 2
Workers Compensation Insurance Information
3. Was the patient involved in a work-related accident? Yes No
If Yes, continue.
Date of Accident:
Is the patient working? Yes No Full Time? Part Time?
Employer Name:
Employer Address:
City State Zip Code
Employer Identification Number:
Name of Insurance Company:
Name of Person or Company Insured:
Insurance Company Claim or Policy Number:
Workers Compensation Claim Number:
Name of Workers Compensation Agency where claim was filed:
Address of Agency:
Has the case been settled? Yes Date No
Name of Patient's Legal Representative for the case if any:
Phone Number of Legal Representative:
Veteran's Administration (VA) Authorization Information
Does the patient have a VA fee service card? Yes No
Has the VA issued a special authorization for these services? Yes No
Does the patient authorize you to bill the VA? Yes No
Black Lung Insurance Information
Is the patient entitled to benefits under the
Department of Labor's Black Lung Program? Yes No
Are the services provided on the Department of Labor's list of
approved procedures for the treatment of Black Lung Disease? Yes No
Patient Signature Date
Witness Signature Date
? 2003 U.S. Physical Therapy, Inc.

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