Medicare Form

Nether you'll get office forms that you perhaps necessitated to fill in before your office visit.

 PATIEN TNAME: ____________________

1.) Name of partner______________   ________________________________________

2.) Is the patient employed? YES     NO

3.) Is partner or other family member employed? YES     NO

4.) Does patient have employer group health program (EGHP) reportage founded on own or a family
member’s current or early employment? YES     NO

5.) Does the employer that sponsors the EGHP have 20 or more employees?
 YES     NO

6.) Is the patient retired? YES     NO  Is the partner retired? YES     NO
Patient retirement date:_______________ partner retirement date:_______________

7.) Is patient entitled to Medicare as of end stage renal disease (ESRD)? YES NO

8.) Is patient entitled to Medicare as of disablement other than ESRD? YES NO

9.) Does employer that sponsors patient’s GHP have 100 or more employees? YES NO

10.) Is patient entitled to benefits through the Department of Veterans Affairs? YES NO

11.) Does the patient desire the VA to be touched for authorization? YES NO

12.) Is patient entitled to welfares below the federal Black Lung Program? YES NO

13.) Is this sickness/injury covered by a workers recompense claim? YES NO

14.) Is this sickness/injury the consequence of a non-work related accident? YES NO

15.) Are services addressed by a Public Health service or research programme? YES NO
INFORMATION SUPPLIED BY:___________________________________________________

RELATIONSHIP TO PATIENT: SELF partner OTHER:___________________________

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