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Medicare Patient Information
Name________________________________________________________________________________
  First M.I. First
Date of Birth_______/_______/_______ Age:______ Sex:_________
Home Address ________________________________________________________________________
  Street
  _______________________________________________________________________
  City State Zip Code
Home Phone (      )_________________________Work Phone (     )_______________________________
       
Please answer each of the following as they apply to you. If it does apply to you, please check YES. If it does not apply to you, please check NO.
       
YES NO    
Do you or your spouse work in a company which has more than 20 employees?  
Are you covered by an HMO/PPO which makes Medicare secondary?  
Are you coming to this office for an illness or accident that has been covered or is authorized for coverage from the VA?(Veteran’s Administration)  
Are you eligible for any benefits under the Federal Black Lung Program?  
Are you coming to this office for an illness, accident, or injury that is the result of an automobile accident?  
Are you coming to this office due to Medicare disability coverage?  
Are you covered by the Federal End Stage Renal Disease Program?  
Are you presently receiving Worker’s Compensation?  
Is the illness or injury you are coming to this office for the result of work related causes?  
Do you have medical assistance through Welfare or state-aid?  
If you answered YES to any of the above questions: ___________________________________________
  Name of Company  
Policy Number _____________________________ Group Number_______________________________
Name of a close relative or friend _________________________________________________________
Phone Number (       )__________________________
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Medicare Patient Information
Name as it appears on your Medicare Card: _________________________________________________
Medicare Health Insurance Claim Number as it appears on your card: _________________________________________________
(This is usually your social security number. Be sure to include the letter after the nine digit number. It is important that we have both the number and the letter.)
Please sign so that we may have your Medicare authorization on file:
I authorize any holder of Medicare or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier of any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the part who accepts assignment. Regulations pertaining to Medicare assignment benefits apply.
Date: _____________________________ Signature:_________________________________________
In the event of a major hospitalization, we request secondary insurance information for records (supplemental Medicare insurance info.) Please fill out below if you are covered by a plan which covers the 20% NOT covered by Medicare. (Medigap Coverage)
Name of Insurance Company: ____________________________________________________________
Policy Number _____________________________ Group Number_______________________________
Please sign so we may have your supplemental authorization on file: I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release the above MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services.
Date: _____________________________ Signature:_________________________________________
 
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