If yes, dates of hospital stay ____________________________
Medicare Supplement (Medi-Gap) Payor _______________________________________________________ Phone # ____-____-____ Policy # ________________________________ Billing Address (if not on card) ___________________________________ Medi-Gap Plan Type ___________________________________________ If not Medi-Gap, does the plan pay Medicare A or B coinsurance _____________________________________ Medicare Information Medicare Number: ________________________________________ Medicare A Active Date _____________________ Medicare B Active Date ___________________________ MSP Coverage □Yes □No
Open Hospice Election □Yes □No
Medicare Advantage Coverage □Yes □No *If yes, complete Insurance Primary Section Med A – Days Available ________ Med B – Therapy Used ________________________ Qualifying Hospital Stay
□Yes □No
Date span of qualifying hospital stay ____________________________ Medicaid
Medicaid Number: __________________________________ Active Coverage □Yes □No All applicable paperwork submitted to state □Yes □No Monthly Patient Liability Amount $ _________________
Attach front and back copies of Medicare, Medicaid and insurance cards and eligibility screenshots if not scanned electronically. Disclaimer: Use of this form is no guarantee of payment or that all payor requirements have been met.