Patient Name: ________________________________ Date: ____________________

ATTENTION ALL MEDICARE RECIPIENTS

Secondary Payer Questionnaire

The “Secondary Payer Questionnaire” is a set of standard questions that Medicare requires providers to

address at EVERY visit with all patients participating in the Medicare program.

Please review the following questions and alert us to any changes:

1. Are you receiving Black Lung Benefits? YES NO

2. Are the services to be paid by a government research program? YES NO

3. Has a Department of Veteran’s Affairs (DVA) authorized and agreed to pay for your care at the facility?

YES NO

4. Was the illness/injury related to a non-work related accident? YES NO

5. Was the illness/injury related to a work related accident/condition? YES NO

6. Is Medicare your Primary Insurance? YES NO

7. Are you entitled to Medicare based on:

a. Age

b. Disability

c. End-Stage Renal Disease

8. Are you currently employed? YES NO (retired) NO (never employed)

9. Do you have group health coverage based on your own or a spouse’s current employment?

YES (both) YES (self) YES (spouse) NO

PHONE 402-562-4720

FAX 402-562-4721

4508 38th Street, Suite 152

Columbus, Nebraska 68601

www.columbusotolaryngology.com