Medicare Sign Up pack sample

MEDICARE SECONDARY PAYER QUESTIONNAIRE Patient’s Name: _________________________________ Med. Rec. No.: __________________ 1. Is the patient covered by Veterans Administration, Bla c k Lung, or Workers Compensation? Paciente cubierto por la Administración de Veteranos □ Yes □ No A. Date of Workers Compensation Accident?___________________ Fecha del accidente 2. Was illness due to an injury? □ Yes □ No La enfermedad se debe a un golpe/accidente A. Date of Accident? _____ / _____ / _____ Fecha del accidente B. What type of accident caused illness/injury? If fall, explain in detail. Explique tipo de accidente, si fue una caida explique detalladamente. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ C. Is the patient filing or intending to file a liability suit? □ Yes □ No Hará el paciente una demanda? Escriba el nombre del abogado. If yes, give name, address and telephone number of attorney? Name of the attorney: ________________________________________________ Address: __________________________________________________________ Telephone No.: ____________________________ 3. Is the patient employed (Medicare disabled beneficiaries under age 65 or Medicare beneficiaries over 65) and covered by a group health plan? □ Yes □ No El paciente trabaja, o está cubierto por un seguro de grupo. A. Date of retirement: _____ / _____ / _____ Fecha del retiro B. Is the patient married? □ Yes □ No Casado C. Is the spouse employed? □ Yes □ No Esposa/o trabaja D. Does the spouse have group coverage? □ Yes □ No El esposo/a tiene seguro E. Does the patient have coverage through a spouse, parent or guardian’s employer group health plan? □ Yes □ No Tiene el paciente seguro a travez de la esposa, padres or guardian. F. If you answered yes to either 3, 3D, 3E you will need to fill out the information below: (Si es aplicable, llene los datos de la Compañía de Seguro) Insurance Company: ______________________________________________________ Address: ________________________________________________________________ Policy/Certification Number: _________________________________________________ Group Name: ____________________________________________________________ Group Number: ___________________________________________________________ 4. Is the patient entitled to benefits solely on the basis of end state renal disease? □ Yes □ No El paciente recibe los beneficios, solo por problemas renales. A. Has the patient been undergoing kidney dialysis for more than 12 months? □ Yes □ No El paciente está en dialysis por más de 12 meses. ( REMEMBER IT IS THE AGENCY’S RESPONSIBILITY TO BILL PRIMARY INSURERS) Staff’s Signature: _________________________________________ Date: ______________ Remarks: _____________________________________________________________________ _____________________________________________________________________________ sample