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MEDICARE INFORMATION

If you are age 65 or older, have end stage renal failure, or are permanently disabled, you may qualify for Medicare benefits. Medicare Part A provides benefits for In-Patient hospitalization. Medicare Part B provides benefits for ambulatory surgery, pre-surgical testing, physician services and diagnostic testing. Your Medicare card will indicate if you have Part A or B, or both, and their effective dates. The time limit to submit a Medicare claim for services rendered from January through September is December 31 of the following calendar year. Services provided from October through December are considered rendered in the next calendar year. If you are 65 or over, but you or your spouse are still actively employed, your employer group health plan may be primary.

If you are a Medicare beneficiary, please provide the following information so we can submit a claim or follow-up on a previously submitted claim.

 

Medicare Beneficiary:
Patient Name:
Phone Number:
Email:
Client Account # (see letter):

Medicare ID# (please include suffix):

Part A Effective Date (MM/DD/YYYY):
Part B Effective Date (MM/DD/YYYY):  
 
If you are a member of a Medicare HMO, please provide the following information:
 

Medicare HMO:

HMO Name:
HMO Address:
City:
State:
Zip:
Insurance Carrier Phone:
Identification#:
Effective Date (MM/DD/YYYY):
Termination Date (MM/DD/YYYY):
 
   
 

If you have insurance coverage supplemental to Medicare that will pick up costs after Medicare’s payment, please provide that information as well in the Primary Insurance Form above.

The foregoing information is provided as a service to you and is not intended as legal advice. Any questions you have regarding your legal rights should be directed to your attorney or legal advisor.

HFS IS A DEBT COLLECTOR, AND ANY INFORMATION WE OBTAIN WILL BE USED TO COLLECT THE DEBT.

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