MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C53989.5AA14B70" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C53989.5AA14B70 Content-Location: file:///C:/6A84CAAD/2005MedicareSecondaryconsentform.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" South Of Market Health Center

Clinic Name

Family Medi= cal Clinic

 

 

 

Patient’s Name = ­­­­­­­­­­­­­­­= ­­­­­­________________________________                &= nbsp;   Medicare # ­­­­­­­­­­­­­­&sh= y;­­­_______________________

 

 

§        Medicare Secondary Payer Screening Questionnaire=

 

1.    Are you covered by t= he Veterans Administration, the Black Lung

Program or Workers Compensation? If so which one? ­____________________<= /o:p>

 

(     ) Yes

(     ) No

2.    Is this illness or i= njury due to any type of accident?

 

(     ) Yes

(     ) No

3.    Are you age 65 or ol= der

 

(     ) Yes

(     ) No

       &nbs= p;      a.   Are you cur= rently employed?

 

(     ) Yes

(     ) No

       &nbs= p;      b.   Is your spo= use currently employed?

 

(     ) Yes

(     ) No

4.   Are you age 65 or under?

 

(     ) Yes

(     ) No

       &nbs= p;     a.    Are y= ou covered by any employer Group Health Plan?

 

(     ) Yes

(     ) No

       &nbs= p;     b.   Or another = large Group Health Plan?

 

(     ) Yes

(     ) No

 

&= sect;      =   Authorization Statement and Pay= ment Agreement

I declare under penalty of perjury that I do not have another primary insuran= ce carrier to pay for medical care rendered to me by _________________________= ___________, and that all information with regard to residence, employment, and income is correct to the best of my knowledge.

 

I request that payment of authorized Medicare Benefits be made to this health center for any services furnished to me by its physicians or suppliers.

 

I understand that my signature requests that payment be made and that it authorizes release of medical information necessary to pay the claim(s).  If a secondary insurance carrier is involved my signature also authorizes releasing information to the insurer = or agency shown.

 

In Medicare assigned cases, the physician or supplier agrees to accept the cha= rge determined by the Medicare Carrier as full charge, and the patient is responsible only for the deductible (Excluding UGS/Medicare) coinsurance and non-covered services.  Coinsur= ance and deductible are based upon charge determined by the Medicare carrier.

 

 

 

____________________________________________________               &= nbsp;       __________________________= ______

Signature of Patient or Authorized Representative&nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;     Date

 

 

____________________________________________________        &= nbsp;           &nbs= p;  ________________________________

Witnessed by       = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            = Date

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