Medicare questionnaire pdf 2026

1. Click ‘Get Form’ to open the Medicare Secondary Payer Questionnaire in the editor.
2. Begin by answering question 1 regarding benefits from specific programs. Select 'Yes' or 'No' for each program listed.
3. For question 2, indicate if your illness or injury was work-related by selecting 'Yes' or 'No', and provide the date of the incident.
4. In question 3, specify if your illness/injury was due to a non-work-related accident. Again, select 'Yes' or 'No', and detail the type of accident.
5. Proceed to question 4 to confirm your entitlement to Medicare based on age, disability, or end-stage renal disease.
6. Answer questions 5 and 6 about current employment status for yourself and your spouse.
7. In question 7, indicate whether you have group health plan coverage related to current employment.
8. Question 8 asks if the employer sponsoring your GHP has 20 or more employees; respond accordingly.
9. Finally, confirm if you are currently a patient in a skilled nursing facility in question 9.
10. Complete the form by signing and printing your name at the bottom to confirm that all information is correct.

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