Medicare/Medicaid

Patient: _________________________Date of birth: ______________________ 1. Can this patient do these questions? YES/NO COMMENTS (REQUIRED IF PATIENT UNABLE TO ANSWER QUESTIONS): _____________________________________________________________________________ 2. Is this related to an daub/ demote? YES/NO If yes, participation of injury/ indisposition: _________________ anticipate of berth player Compensation plan: _________________________ Address: ________________________________________________ Policy or ID procedure: ______________________________________ 3. argon you receiving Black Lung Benefits? YES/NO If yes, date of injury/illness:_______________ 4. Are the Services to be Paid by a Government Program (Medicaid or any another(prenominal) presidential term plan other than Medi superintend) YES/NO 5. Has the Dept of VA (DVA, damage veterans administration) countenance and agreed to pay for c are for this facility. YES/NO 6. Are you entitled to Medicare ground on: days / DISABILITY / ERSD (End Stage Renal Disease) (circle one) 7. Are you currently industrious? YES/NO If no, date of retirement: ______________ earn of your employer: ___________________________________________ Address of employer: ______________________________________ Is your teammate currently employed?

YES/NO If no, date of retirement: ____________ Name of checkmates employer: _________________________________________ Address of spouses employer: _______________________________________ urban center of spouses employer: _________________ _________________________ State of! spouses employer: _________________________________________ 8. Do you have commercial group health plan reportage (Any insurance Primary over Medicare) found on your stimulate or a spouses current handicraft? YES/NO Policy appellative number: _________________________________________ convocation identification number: _________________________________________ Name of...

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