Form 3 of 9
Please enter your Information:
PART I:
PART II:
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:
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?
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.