Medicare Secondary Payer Questionnaire Template - Albany Medical Center

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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
Print Form
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
4e. If the patient is covered under an insurance plan through the current employer of anyone, including self,
does the employer employ 100 or more employees? Yes ____ or No _____
5. Is the patient entitled to Medicare based on End Stage Renal disease? Yes ____ No ____ If no, go on to
question 6
5a. Has the patient received self-dialysis training (home dialysis)? Yes ____ or No _____
If Yes; date started: _________
5b. Has the patient received maintenance dialysis (hemodialysis) Yes ___ or No ____
If yes; date started: _________
5c. Has the patient received a kidney transplant? Yes ____ or No ____ If Yes, when: ________________
5d. Is the patient within the 30-month coordination period? Yes ____ or No ____
5e. Is the patient entitled to Medicare based on ESRD and age or ESRD and disability? Yes ____ or No ____
5f. Was the patient’s initial entitlement based on ESRD? Yes ____ or No ____ If no, go to 5g, else go to 6
5g. Initial entitlement to Medicare was based on age or disability: is all criteria for working aged/disability
rule present? Yes ____ or No ____
6. Is today’s service related to a Workers Compensation case? Yes ___ or No ___ If Yes, complete Part II
7. Is today’s service related to a No Fault (auto accident)? Yes ____ or No ____ If Yes, complete Part II
8. Is today’s service related to a liability case in which another party is responsible? Yes ____ or No ____
If Yes, complete Part II
9. Is any other program responsible for payment of today’s services; check any that apply:
Black Lung_____ Veterans Administration ____ Research Grant ________ other ______________
If any apply, complete Part III
PART II
Workers compensation, No fault, liability information
Date of accident or injury: _______________________
Policy #: ______________________ Insurance name: ______________________________________________
Insurance address ________________________________City ______________ State _______ Zip _______
If Workers compensation related:
Employer name: __________________________________
Employer address ________________________________ City ______________ State _______ Zip _______
PART III
Other program responsible for payment information
If research grant or study, study name: ________________________________________________________
If Veterans Administration, has VA authorized the service? Yes ____ or No ____
If Black Lung benefits, date these benefits began: ____________
MSP questionnaire2.doc
Rev 06/07/07

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