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Medicare Secondary Payer Questionnaire (MSPQ) - medicare msp questionnaire printable


Medicare Secondary Payer Questionnaire (MSPQ)-medicare msp questionnaire printable

Medicare Secondary Payer Questionnaire (MSPQ)
OFFICE USE ONLY
Patient Name:_______________________________ Date of Birth: ______________ MRN: ______________________
Date of Visit: ________________
Part I
1. Are you receiving Black Lung (BL) Benefits?
Yes Date benefits began: ______/______/_______
No
2. Are services covered by a government program (research)?
Yes Government Research Program will pay primary benefits for these services
No
3. Has Dept of Veteran Affairs agreed to pay for care?
Yes
No
4. Was illness/injury due to work related accident?
Yes Date of accident: ______/______/_______
Name and address of workers compensation plan:
________________________________________________
________________________________________________
No ------> GO TO PART II
Part II
1. Was illness/injury caused by a non-work related accident?
Yes Date of accident: ______/______/_______
Name and address of workers compensation plan:
________________________________________________
________________________________________________
No ------> GO TO PART III
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Medicare Secondary Payer Questionnaire (MSPQ)
Part III
1. Are you entitled to Medicare benefits based on:
Age
Disability
End Stage Renal Disease
Part IV
1. Do you have current employment status?
Yes
No If applicable, date of retirement? ______/______/______
No Never employed
2. Do you have a spouse with current employment status?
Yes
No If applicable, date of retirement? ______/______/______
No Never employed
3. Do you have group health plan coverage based on your own, or a spouse's current employment?
Yes Both
Yes Self
Yes Spouse
No ------> GO TO PART V
Part V
1. Are you retired due to disability?
Yes If applicable, date of retirement? ______/______/______
No
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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...