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MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE - medicare msp questionnaire printable

MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE-medicare msp questionnaire printable

Last Name (Legal) First Name, Middle Name (Legal) Date of Birth
Medicare Number
Part A Part B
MSP GENERAL INFORMATION (Required for all Medicare Patients)
1 Is Medicare entitlement based on age? Yes No
2 Are you currently employed? Yes No
3 Is your spouse currently employed? Yes No
4 Are you covered by a health plan from you own or spouse's current employer? Yes No
Does the employer have 20 or more employees? Yes No
5 Are you or your spouse retired? Yes No
Your retirement date: __________ / ___________ / ____________
Your spouse's name: ____________________________________
Your spouse's retirement date: __________ / ___________ / ____________
6 Are you entitled to Medicare because of end stage renal disease (ESRD)? Yes No
Are you within the first 30 months of treatment for ESRD? Yes No
7 Are you entitled to Medicare because of disability, other than ESRD? Yes No
Are you covered by a group health plan of an employer with over 100 employees? Yes No
8 Has the Department of Veterans Affairs (VA) authorized and agreed to pay for the services at this facility today? (If yes, please Yes No
provide authorization form)
9 Are you entitled to the benefits under the Federal Black Lung Program? Yes No
10 Is this illness/injury due to a work-related accident/condition? Yes No
11 Is this illness/injury the result of a non-work related accident (i.e. motor vehicle accident)? Yes No
12 Are you to be paid by a government research program? If yes, please provide billing instructions to the front desk Yes No
Information supplied by Relationship to Patient
Self Spouse Other ____________________
This form is intended for Medicare billing purposes only. If you have answered yes to any of the above questions or are receiving
Medicare benefits due to Disability or ESRD more information will be required during your registration/check-in process.
Print Name Date
Patient Signature
We do not discriminate on the basis of race, color, national origin, sex, age, or
disability in our health programs and activities. PLACE PATIENT LABEL HERE
Today's Date:
Official Use Patient Name:
MRN: Date of Birth:
Swedish NC 0003 ADMIN (Rev. 6/29/2018)

How to complete required Medicare questionnaire? It can also include: A review of your medical and family history. Developing or updating a list of current providers and prescriptions. Height, weight, blood pressure, and other routine measurements. Detection of any cognitive impairment. Personalized health advice. A list of risk factors and treatment options for you. More items...