Medicare Secondary Payor Questionnaire (MSPQ) Step 1 of 2 50% If you have Medicare or a Medicare replacement plan, please complete this form.Name First Last ACS LocationSelect a LocationArizona Orthopedics Desert Podiatric – Green ValleyDesert Podiatric – TucsonDesert Podiatric – Oro ValleyHess & Sandeen Plastic SurgeryHurst Plastic SurgerySouthern Arizona Infectious Disease SpecialistsPart 1Are you receiving Black Lung (BL) benefits? Yes No Date Black Lung benefits began Are these services related to Black Lung?Is the diagnosis on the Dept of labor list? Yes No Are the services to be paid by a government research program/project? Yes No Has the DVA authorized and agreed to pay for the care at this facility? Yes No Are you entitled to benefits through the Department of Veterans Affair (DVA)? Yes No Was the illness/injury due to a work-related accident/condition? Yes No Part 2Was the illness/injury due to a non-work-related accident? Yes No Date of accident Is no-fault insurance available? Yes No Is additional no-fault insurance available? Yes No Is liability insurance available? Yes No Is additional liability insurance available? Yes No Provide name and address of no-fault and/or liability insurer(s) and responsible partyInsurance claim number(s)Part 3Are you entitled to Medicare based on Age, Disability, or End-stage Renal Disease?? Age Disability End-Stage Renal Disease Are you currently employed? Yes No Current employer name and address:If applicable, date of retirement: MM slash DD slash YYYY Do you have a spouse who is currently employed? Yes No If applicable, date of spouse retirement: MM slash DD slash YYYY Spouse current employer name and address:Do you have a group health plan (GHP) coverage based on your own current employment? Yes No Do you have a group health plan (GHP) coverage based on your spouse’s current employment? Yes No Do you have GHP coverage based on your own current or former employment? Yes No If you have GHP coverage based on you own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? Yes No If you have GHP coverage based on you own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? Yes No Do you have GHP coverage through your spouse? Yes No If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer that sponsors or contributes to the GHP employ 20 or more employees? Yes No If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer that sponsors or contributes to the GHP employ 100 or more employees? Yes No Are you covered under a GHP based on the employment of a family member other than a spouse? Yes No If you have GHP coverage based on a family member’s current employment, does your family member’s employer that sponsors or contributes to the GHP employ 100 or more employees? Yes No Do you have GHP coverage through a family member other than your spouse? Yes No Have you received a kidney transplant? Yes No Have you received maintenance dialysis treatment? Yes No Have you participated in self-dialysis training program? Yes No Are you within the 30-month coordination period? Yes No Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability? Yes No Was your initial entitlement to Medicare (including simultaneously or dual entitlement, based on ESRD? Yes No Does the working aged disability MSP provision apply (i.e. is the GHP already primary based on age or disability entitlement)? Yes No If covered by a GHP, provide: name, address, and policy informationHiddenpartnerid Hiddenpartneremail Δ