Medicare Skilled Nursing Facility Admission Notice

Form 4 of 12

Please enter your Information:

Sex: *

  

  

  

  

  

  


PART I:

BL IS PRIMARY ONLY FOR CLAIMS RELATED TO BL.

*2. Are the services to be paid by a government program such as a research grant?



*3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility?



*4. Was the illness/injury due to a work related accident/condition?

WC IS PRIMARY PAYER ONLY FOR CLAIMS RELATED TO WORK RELATED INJURIES OR ILLNESS, GO TO PART III.

 


PART II:

*1. Was illness/injury due to a non-work related accident?


*2. Is no-fault insurance available? (No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.)

*3. Is liability insurance available? (Liability insurance is insurance that protects against claims cased on negligence, inappropriate action or inaction, which results in injury to someone or damage to property.)

NO-FAULT INSURER IS PRIMARY PAYER ONLY FOR THOSE SERVICES RELATED TO THE ACCIDENT. LIABILITY INSURANCE IS PRIMARY PAYER ONLY FOR THOSE SERVICES RELATED TO THE LIABILITY SETTLEMENT, JUDGMENT, OR AWARD. GO TO PART III.


PART III:

*Are you entitled to Medicare based on:




Please Note: Both "Age" and "ESRD" or "Disability" and "ESRD" may be selected simultaneously.
An individual cannot be entiled to Medicare based on "Age" and "Disability" simultaneously. Please complete ALL "PARTS" associated with the patient's selections.


PART IV: AGE

Are you Currently Employed?

2. Do you have a spouse who is currently employed?

IF THE PATIENT ANSWERED "NO" TO BOTH QUESTIONS 1 AND 2, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED "YES" TO QUESTIONS IN PART I OR II. DO NOT PROCEED FURTHER.

3. Do you have Group Health Plan (GHP) coverage based on your own, or based on a spouse's current employment?






4. If you have GHP coverage based on your own current employment, does your employer which sponsors or contributes to the GHP, employ 20 or more employees?

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):


5. If you have GHP coverage based on your spouse's current emplyment, does your spouse's employer that sponsors or contributes to the GHP, employ 20 or more employees?

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):

IF THE PATIENT ANSWERED "NO" TO BOTH QUESTIONS 4 AND 5, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED "YES" TO QUESTIONS IN PART I OR PART II. DO NOT PROCEED FURTHER.

PART V: Disability

1. Are you Currently Employed?

2. Do you have a spouse who is currently employed?

3. Do you have Group Health Plan (GHP) coverage based on your own, or based on a spouse's current employment?





4. Are you covered under the group health plan of a family member other than your spouse?

IF THE PATIENT ANSWERED “NO” TO BOTH QUESTIONS 3 AND 4, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II. DO NOT PROCEED FURTHER.

5. If you have GHP coverage based on your own current employment, does your employer which sponsors or contributes to the GHP, employ 100 or more employees?

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):


6. If you have GHP coverage based on your spouse's current employment, does your spouse's employer which sponsors or contributes to the GHP, employ 100 or more employees?

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):


7. If you have GHP coverage based on your family member's current employment, does your family member's employer which sponsors or contributes to the GHP, employ 100 or more employees?

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):

IF THE PATIENT ANSWERED “NO” TO BOTH QUESTIONS 3 AND 4, MEDICARE IS PRIMARY UNLESS THE PATIENT ANSWERED “YES” TO QUESTIONS IN PART I OR II. DO NOT PROCEED FURTHER.

PART VI: ESRD

1. Do you have Group Health Plan (GHP) coverage?

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):

IF APPLICABLE, YOUR SPOUSE'S GHP INFORMATION

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):

IF APPLICABLE, YOUR FAMILY MEMBER'S GHP INFORMATION

(This number is sometimes referred to as the health insurance benefit package number):

(Prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual's Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):


3. Have you received maintenance dialysis treatments?

4. Are you within the 30-month coordination period?

(The 30-month coordination period starts the first day of the month an individual is eligible for Medicare [even if not yet enrolled in Medicare] because of kidney failure [usually the fourth month of dialysis]. If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.)

STOP. MEDICARE IS PRIMARY

5. Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability?



7. Does the working aged or disability MSP provision apply (i.e., is the GHP already primary based on age or disability entitlement?)?



By submitting this Authorization, please be aware that an electronic signature is as legally binding as a handwritten signature.