Medicare Skilled Nursing Facility Admission Notice

Form 4 of 11

Please enter your Information:

Resident Name: *

Sex: *

MaleFemale

Was resident admitted to any hospital within the last year?: *

YesNo

If so, when?

Where?

Was resident admitted to a Skilled Nursing Facility in the last year?: *

YesNo

If so, when?

Where?

Does Resident have a fracture?: *

YesNo

How did it happen?

Where did it happen?

Has the resident ever had a worker compensation claim? *

YesNo

What was the injury?

When did it happen?

PART I:

1. Are you receiving Black Lung Benefits (BL)? *

Yes If yes, Date Benefits Began:*

NoBL IS PRIMARY ONLY FOR CLAIMS RELATED TO BL.

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

Yes GOVERNMENT WILL PAY PRIMARY BENEFITS FOR THESE SERVICES
No

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

Yes DVA IS PRIMARY FOR THESE SERVICES
No

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

Yes

If Yes, Date of injury/illiness:

Name and address of WC plan

Policy or identification number:

Name and address of your employer:

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

No (4) GO TO PART II

PART II:

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

Yes Date of accident::

No GO TO PART III

*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.)

Yes

Name and address of no-fault insurer(s) and no-fault insurance policy owner:

Insurance claim number:

No (2)

*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.)

Yes

Name and address of no-fault insurer(s) and no-fault insurance policy owner:

Insurance claim number:

No (3)

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:

Age GO TO PART IV
Disability GO TO PART V
ESRD Go to Part VI. (End Stage Renal Disease)

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?

Yes Name and address of your employer:

No Date of retirement, if applicable

No, never employed

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

Yes Name and address of employer

No If applicable, date of retirement:

No, never 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?

Yes, both
Yes, self
Yes- spouse
No STOP. MEDICARE IS PRIMARY PAYER UNLESS THE PATIENT ANSWERED YES TO THE QUESTIONS IN PART I OR II.

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?

Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION:

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (4)

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?

Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION:

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (5)

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?

Yes Name and address of your employer

No Date of retirement, if applicable

No, never employed

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

Yes Name and address of your employer

No Date of retirement, if applicable

No, never employed

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

Yes, both
Yes, self
Yes , spouse
No

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

Yes Name and address of your employer

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?

Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION:

Name and address of GHP

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (5)

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?

Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION:

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (5)

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?

Yes. GHP IS PRIMARY. OBTAIN THE FOLLOWING INFORMATION:

Name and address of GHP:

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

Group Identification Number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (5)

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?

Yes. IF APPLICABLE, YOUR GHP INFORMATION:

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

IF APPLICABLE, YOUR SPOUSE'S GHP INFORMATION

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

IF APPLICABLE, YOUR FAMILY MEMBER'S GHP INFORMATION

Name and address of GHP:

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

Group identification number

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

No (1) STOP MEDICARE IS PRIMARY

2. Have you received a kidney transplant?

If yes, Date of Transplant:

3. Have you received maintenance dialysis treatments?

If yes, Date dialysis began:

If you participated in a self-dialysis training program, provide date training started:

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.)

Yes

If yes, Start Date:

NoSTOP. MEDICARE IS PRIMARY

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

YesNo

6. Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD?

Yes STOP. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD
No INITIAL ENTITLEMENT BASED ON AGE OR DISABILITY

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

Yes STOP. GHP CONTINUES TO PAY PRIMARY DURING THE 30-MONTH COORDINATION PERIOD
No MEDICARE CONTINUES TO PAY PRIMARY

Resident Signature (Responsible Person / Guardian) *

Date: *

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

Form 4 of 11

Please enter your Information:

Resident Name: *

Sex: *

Was resident admitted to any hospital within the last year?: *

If so, when?

Where?

Was resident admitted to a Skilled Nursing Facility in the last year?: *

If so, when?

Where?

Does Resident have a fracture?: *

How did it happen?

Where did it happen?

Has the resident ever had a worker compensation claim? *

What was the injury?

When did it happen?

PART I:

1. Are you receiving Black Lung Benefits (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?

If Yes, Date of injury/illiness:

Name and address of WC plan

Policy or identification number:

Name and address of your employer:

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.)

Name and address of no-fault insurer(s) and no-fault insurance policy owner:

Insurance claim number:

*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.)

Name and address of no-fault insurer(s) and no-fault insurance policy owner:

Insurance claim number:

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?

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to 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?

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to patient:

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?

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?

Name and address of GHP

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to 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?

Name and address of GHP:

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

Group identification number:

Membership 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):

Name of Policyholder / named insured:

Relationship to 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?

Name and address of GHP:

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

Group Identification Number:

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.