Activeforever Uplift Seat Assist - Manual

IMPORTANT – SEE OTHER SIDE FOR INSTRUCTIONS
PLEASE TYPE OR PRINT INFORMATION MEDICAL INSURANCE BENEFITS SOCIAL SECURITY ACT
PATIENT’S REQUEST FOR MEDICAL PAYMENT
Signature of Patient (If patient is unable to sign, see Block 6 on reverse) Date signed
NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under
Federal law. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (20 CFR 422.510).
FORM APPROVED
OMB NO 0938-0008
Name of Beneficiary from Health Insurance Card SEND COMPLETED FORM TO:
(Last) (First) (Middle)
1
2
3
4
5
6
3b
4b
4c
Patient’s Sex Claim Number from Health Insurance Card
■ ■
Male
■ ■
Female
Patient’s Mailing Address (City, State, Zip Code)
Check here if this is a new address
■ ■
(Street or P.O. Box – Include Apartment Number)
(City) (State) (Zip)
Describe the illness or injury for which patient received treatment
Telephone Number
(Include Area Code)
a. Are you employed and covered under an employee health plan?
■ ■
Yes
■ ■
No
b. Is your spouse employed and are you covered under your spouse’s employee
health plan?
■ ■
Yes
■ ■
No
c. If you have any medical coverage other than Medicare, such as private insurance, employment related insurance,
State Agency (Medicaid), or the VA, complete:
Name and Address of other insurance, State Agency (Medicaid), or VA office
Policyholder’s Name:
Note: If you DO NOT want payment information on this claim released, put an (X) here
■ ■
Condition was related to:
A. Patient’s employment
■ ■
Yes
■ ■
No
B. Accident
■ ■
Auto
■ ■
Other
Policy or Medical Assistance No.
I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION
AND CENTERS FOR MEDICARE & MEDICAID SERVICES OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A
RELATED MEDICARE CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL, AND REQUEST PAYMENT
OF MEDICAL INSURANCE BENEFITS TO ME.
6b
IMPORTANT
ATTACH ITEMIZED BILLS FROM YOUR DOCTOR(S) OR SUPPLIER(S) TO THE BACK OF THIS FORM
Was patient being treated with
chronic dialysis or kidney transplant?
■ ■
Yes
■ ■
No
( )
_
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Your Medicare Carrier
If you need help, call 1-800-MEDICARE
(1-800-633-4227)
Form CMS-1490S (SC) (01/05) EF 02/2005