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Medicare Patient Infomation

Name
Address
City
State
 Zip
Home Phone
Work Phone
Social Security
Date of Birth
 Sex M F
Marital Status
 Single Married Divorced Widowed Separated

Please read each of the following and answer as they apply to you. If it does apply to you, please check YES. If it does NOT apply to you, please check NO.
 Yes    No
  
  
Do you or your spouse work in a company wich has more than 20 employees and have coverage through the insurance at that job?
  
Are you covered by a HMO/PPO which makes Medicare secondary?
  
Are you coming to this office for an illness or accident that has been covered or is authorized for coverage from the Veteran's Association?
  
Do you or spouse work and have coverage through the insurance at your job?
  
Are you eligible for any benefits under the Federal Black Lung Program?`
  
Are you coming to this office for an illness, accident, or illness that is the result of an automobile accident?
  
Are you coming to this office due to Medicare disability coverage?
  
Are you covered by the Federal End Stage Renal Disease Program?
  
Are you presently receiving Workers' Compensation?
  
Is the illness or injury you are coming to this office for the result of work-related causes?
  
Do you have medical assistance through Welfare or state-aid?
 
If you answered YES to ANY of the above questions:
Insurance Information (Please present insurance card at time of check in.)
Primary Insurance Name
Ins. Address
Name of Insured
Insured's ID#
Group #
Employer Name
Employer Address
Employer Phone
Relationship of patient to the Insured
Emergency contact
 Phone
Name on Medicare Card
Medicare Claim Number
 (include letter after 9 digit number)

The following sections require your signature and will be completed upon your arrival at the office.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

Date ________ Signature _______________________________________________

In the event of a major procedure or hospitalization, we request secondary insurance information for our records (supplemental Medicare insurance information). Please fill out below if you are covered by a plan which covers the 20% NOT covered by Medicare. (Medigap Coverage)

Name of Insurance Company:
Policy Number: Group Number:

Recheck to make sure all above information is correct, then press submit.

 
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