1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PATIENT222S REQUEST FOR MEDICAL PAYMENT IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR 226 Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid for under the DMEPOS Competitive Bidding program. Your reason for submitting this claim: The provider or supplier refused to 037le a claim for Medicare Covered Services The provider or supplier is unable to 037le a claim for the Medicare Covered Services The provider or supplier is not enrolled with MedicareIF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048. Type of Patient222s Request (see instructions for additional information, check one box only): Influenza/Pnmococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign Durable Medical Equipment, Prosthetics, Orthotics and Supplies PLEASE TYPE OR PRINT INFORMATIONForm ApprovedOMB No. SECTION 1 - PATIENT INFORMATIONPatient222s Name as shown on Medicare Card (Last, First, Middle)Patient222s Medicare Number exactly as it is shown on the Medicare card:Date of Birth (mm/dd/yyyy) Male FemaleStreet address (or P.O. Box - include apartment number)CityStateZip code Telephone number American LegalNet, Inc. www.FormsWorkFlow.com 2 SECTION 2 - INFORMATION ABOUT SERVICES FURNISHEDFOR ALL CLAIMS including In036uenza and Pneumococcal Vaccinations, describe the illness or injury for which you received treatment. Attach all supporting documentation to the form including an itemized bill with the following information:225Date of service225Place of service225Description of illness or injury225Description of each surgical or medical service or supply furnished225Charge for each service225The doctor222s or supplier222s name and address225The provider or supplier222s National Provider Identifier (NPI) If known ondition related to: Yes No Employment Yes No Auto Accident Yes No Treatment for chronic dialysis or kidney transplant Yes No Other AccidentSECTION 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICAREComplete this section if you are age 65 or older and enrolled in a health insurance plan where you or your spouse are currently working and covered by any medical coverage other than edicare. Yes No Are you employed and covered under an employee health plan? Yes No Is your spouse employed and are you covered under your spouse222s employee health plan? Yes No Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related insurance, Medicaid,or the Veterans Administration (VA)?Name of other Medical InsurancePolicy Number including Medicaid ID NumberPolicyholder222s Name (Last, First, Middle)Street Address (or P.O. Box) of other Medical InsuranceCityStateZip codePlease a a copy of your primary insurer222s Explanation of Benefits if Medicare is secondary. American LegalNet, Inc. www.FormsWorkFlow.com 3 SECTION 4 - SIGNATUREI declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law.I authorize any holder of medical or other information about me to release it to the Centers for Medicare & Medicaid Services or its designated contractor or the Social Security Administration for this 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.Signature of PatientDate Signed (mm/dd/yyyy)If you cannot sign your name, mark an (X) on the signature line. Have a witness sign his/her name next to the 223X224 and complete the section below. If signing this form on behalf of a Medicare patient, on the 221Signature of Patient222 line above, indicate the patient222s name followed by 223By224 and sign your name. Provide your name, address, and relationship to the patient with a brief explanation why the patient cannot sign.Name of Witness (Last, First, Middle)Street AddressCityStateZip codeRelationship to the PatientSignature of WitnessDate Signed (mm/dd/yyyy)Briefly explain why the Patient cannot sign: Send the completed form and supporting documentation to your Medicare contractor. . If you still do not know the address of your Medicare contractor, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to be XX hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Of037cer, Baltimore, Maryland 21244-1850. DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing. American LegalNet, Inc. www.FormsWorkFlow.com 4 COLLECTION AND USE OF MEDICARE INFORMATION We are authorized by the Centers for Medicare & Medicaid Services to ask you for information needed in the administration of the Medicare program. Authority to collect information is in section 205(a), 1872 and 1875 of the Social Security Act, as amended.The information we obtain to complete your Medicare claim is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by Medicare and to insure that proper payment is made.The information may also be given to other providers of services, Medicare Administrative Contractor (MAC), medical review boards, and other organizations as necessary to administer the Medicare program. For example, it may be necessary to disclose information to a hospital or doctor about the Medicare bene037ts you have used.With one exception, which is discussed below, there are no penalties under Social Security law for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of the claim. Failure to furnish any other information, such as name or Medicare number, would delay payment of the claim. It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether worker222s compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminalpenalties for withholding this information. If you are being treated for a work related injury be sure to check the appropriate box in Section 2 titled 221Condition Related to222. Physicians and other suppliers, such as clinical laboratories, imaging service suppliers, and durable medical equipment suppliers are required by law to submit a claim for Medicare covered services furnished to you, the Medicare bene037ciary, within one year of the date of service. To reduce your out-of-pocket expenses, Medicare bene037ciaries should always obtain medical care from physicians and other suppliers who are enrolled in the Medicare program. If you submit a claim for covered services furnished by a physician or other supplier who is not enrolled with the Medicare program, your claim may be denied.For a list of participating Medicare enrolled physicians in your area, please go to www.medicare.gov/physiciancompare or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If a physician or supplier furnishes Medicare covered services to you and refuses to submit a claim on you