Medicare Secondary Payor Form

Information Questionnaire
Form # 72509

Instructions: This questionnaire is for Medicare patients only, and is designed to help Medicare patients determine whether Medicare is primary, secondary, or tertiary coverage. It is a view and print form. (See bottom of form for printing instructions.)
                             
YES NO
1. Is the illness/injury covered by Worker's Compensation?
If Yes
YES NO
  • Enter employer's name, address, & claim number into registration system as Primary. Medicare is listed Secondary.
2. Is this illness/injury covered by the Black Lung Program, Veteran's Administration or any other Federal program?
If Yes
YES NO
  • Enter billing information into registration system as Primary.
3. Is this patient a member of a Health Maintenance Organization (HMO)/Medicare Replacement Plan?
If Yes
YES NO
  • Enter the name and address of the HMO into reg. system as Primary.
4. Is this illness/injury due to an automobile accident or does the patient feel that another party is responsible for this illness/injury?
YES NO
  • IF NO OR NOT KNOWN OR PATIENT IS UNSURE - Enter Medicare into the reg. system as PRIMARY and note in the memo field of the account the questioned responsible party, liability insurer & liability code..
  • If absolutely YES - Enter name of responsible party, liability insurer, & liability code into reg. system as Primary and Medicare as Secondary.
5. Is this patient covered by an Employer Group Health Plan (EGHP), including Federal Employee Health Benefits?
      If No
  • Move to #6
  • Move to Prior Stay Information (at bottom)
YES NO
6. Is this patient age 65 or older?
       If Yes If No
  • Move to #7
  • Move to #8 (A)
YES NO
7. Is this patient or the patient's spouse actively employed by an employer of 20 or more employees?
       If Yes If No
  • Enter the EGHP data into reg. system as Primary.
  • Move to Prior Stay Information (at bottom)
YES NO
8. (A) Is this patient entitled to Medicare coverage solely on the basis of a disability?
       If Yes If No
  • Move to question #8 (B)
  • Move to question #9.
YES NO
8. (B) Is this patient or patient's spouse actively employed by an employer of 100 or more employees?
       If Yes If No
  • Enter the EGHP data into reg. system as Primary.
  • Move to Prior Stay Information (at bottom)
YES NO
9. (A) Is this patient entitled to Medicare solely because of END STAGE RENAL DISEASE (ESRD) and age -or- ESRD and Disability?
       If Yes If No
  • Move to question #9 (B).
  • Enter the EGHP data into reg. system as Primary.
YES NO
9. (B) Has the patient completed the ESRD coordination period?
       If Yes If No
  • Move to Prior Stay Information (at bottom)
  • Enter the EGHP data into reg. system as Primary.
    
PRIOR STAY INFORMATION
Has this patient been confined to a hospital or skilled nursing facility within the last 60 days?
Hospital or SNF: _______________________________________________
Address: _______________________________________________
   
   
Admission Date: _______________________
Discharge Date: _______________________
Who Supplied Info: _______________________________________________
   
Patient Name:
Patient Signature: _______________________________________________
Date: _______________________
   
Witness' Signature: _______________________________________________
Date: _______________________

    

Print:

 

If you have a printer, you may use the Print function on your browser to retain a copy for your records. After you have finished filling out the form, click on the File menu button at the top of your browser and select Print. A copy of your completed form will print out.

For best results, make sure your browser text size is set to Medium (or a Times New Roman, size 12 font).
Fax: You may fax a printed copy to the Business Office at 281-644-7014.
MEMORIAL HERMANN HEALTHCARE SYSTEM
Houston, Texas		 Information Questionnaire
Form # 72509