Page 40 - Home Health Marketing

If “No” to all questions, go to Part 2.
Is the patient receiving benefits under the Black Lung Benefits Act (BL)? o No o Yes Date BL benefits began: ____________________
Note: Black Lung Benefits is the primary payer.
Was the illness or injury due to a work-related accident/illness? o No o Yes If yes, the following information is required:
Name and address of employer: _____________________________________________________________________________________________
Name and address of insurance carrier: _______________________________________________________________________________________
Policy or Claim Number: __________________________________ Date of workplace illness or injury: ___________________________________
Note: Workers’ Compensation is the primary payer only for services related to work-related injuries or illnesses.
SAMPLE
Is the patient receiving treatment for an injury or illness covered under a no-fault and/or medical-payment coverage, including premises
or automobile? o No o Yes If yes, the following information is required:
Name and address of insurance carrier: _______________________________________________________________________________________
Policy or Claim Number: __________________________________ Date of illness or injury: ____________________________________________
Note: No-fault insurance is the primary payer only for services related to the accident.
Is the patient receiving treatment for an injury or illness which another party may be liable? o No o Yes
If yes, the following information is required:
Name and address of insurance carrier: _______________________________________________________________________________________
Policy or Claim Number: __________________________________ Date of illness or injury: ____________________________________________
Note: Liability insurance is the primary payer only for services related to the liability settlement, judgment or award.

Is the patient entitled to Medicare based on age, disability or End Stage Renal Disease (ESRD)?
Age: o Yes o No Disability: o Yes o No ESRD: o Yes o No
Note: If entitlement to Medicare is based solely on ESRD, skip Part 2 and complete Part 3.
Does the patient have group health plan (GHP) coverage based on his/her own current employment or the current employment of either
a spouse or other family member? o Yes o No If no, stop here as Medicare is primary.
Ó MedForms, Inc. 2024
If yes, the GHP provided by the employer may be primary to Medicare. How many employees, including the patient, spouse or other family member
work for the employer providing the GHP coverage? o 1-19 o 20-99 o 100 or more
Note: If the patient is aged and there are more than 20 employees, the patients GHP is primary.
Note: If the patient is disabled and the patient’s spouse or other family member’s employer has 100 or more employees, the GHP is primary.
If GHP may be the primary payer, the following information is required:
Name and address of employer providing the patient’s GHP: ______________________________________________________________________
Name and address of GHP: _________________________________________________________________________________________________
Policy Number (sometimes referred to as the health insurance benefit package number): ________________________________________________
Group Number: _________________________________ Date of illness or injury: GHP coverage began: __________________________________
Name of policy holder (if GHP coverage is through the patient’s spouse or other family member): _________________________________________
Relationship to patient (if other than self): _____________________________________________________________________________________

Does the patient have employer group health plan (GHP) coverage through self, spouse or other family member if dually entitled based
on Disability and ESRD? due to Medicare based on age, disability or End Stage Renal Disease (ESRD)? o No o Yes If yes, the
employer GHP may be primary to Medicare. Continue below:
Has the patient received a kidney transplant? o No o Yes If yes, date of transplant: ______________________________
Has the patient received maintenance dialysis treatments? o No o Yes If yes, date of dialysis began: ___________________________
Is the patient within the 30-month coordination period? o No o Yes Note: 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)
regardless of entitlement due to age or disability. 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.
Was the patient receiving GHP coverage prior to and on the date of Medicare entitlement due to ESRD (or simultaneous entitlement
due to ESRD and Age or ESRD and Disability)? o No o Yes If yes, the GHP is primary during the 30-month coordination
period. The following information is required:
Name and address of employer providing the patient’s GHP: ______________________________________________________________________
Name and address of GHP: _________________________________________________________________________________________________
Policy Number (sometimes referred to as the health insurance benefit package number): ________________________________________________
Group Number: _________________________________ GHP coverage began: _____________________________________________
Name of policy holder (if GHP coverage is through the patient’s spouse or other family member): _________________________________________
Relationship to patient (if other than self): _____________________________________________________________________________________

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