Medicare Information

Medicare law requires that we determine if your medical services might be covered by another insurer. Please answer the following:

Patient Full Name

Medicare law requires that we determine if your medical services might be covered by another insurer. Please answer the following:

Is Your Injury/Illness Due To:

A. Work-related accident/condition?
No Yes B. A Condition Covered Under The Federal Black Lung Program?
No Yes C. An Automobile Accident?
No Yes D. An Accident Other Than An Automobile Accident?
No Yes E. The Fault Of Another Party?
No Yes

2. Are You Eligible For Coverage Under The Veterans' Administration?

No Yes

3. Are you employed?

No Yes

4. Is your spouse employed?

No Yes

5. Are You A Dependent Covered Under A Parent's/Guardian Are Employer Group Health Plan?

No Yes