DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0952 SECTION 1011 PROVIDER PAYMENT DETERMINATION The information collected on this form is used to determine whether a patient’s health care provider is eligible to receive Federal payment under section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The information on this form is only being collected to claim payment for a patient’s health care. This information will be maintained for health care payment and related policy determinations. Providers may not claim a section 1011 payment for United States citizens, lawful permanent residents with a valid I-551 (i.e., Green Card), aliens with a valid I-688B (Employment Authorization Card), or individuals in the United States on a valid non-immigrant visa (such as students, tourists, business travelers, etc.) DO NOT DELAY EMERGENCY TREATMENT AND LABOR ACT SCREENING OR NECESSARY STABILIZING TREATMENT TO REQUEST SECTION 1011 ELIGIBILITY INFORMATION Patient’s Hospital Medical Record Number Patient’s Place of Birth A provider should not ask a patient if he or she is an undocumented alien. However, if the patient informs you that he or she is undocumented, check () this box J. If checked, sign and date page 2. The patient is potentially an eligible individual for section 1011 payment purposes. 1. Is the patient eligible for, or enrolled in, Medicaid? Note: If the patient is eligible for emergency Medicaid, a section 1011 payment may be available for services not covered by emergency Medicaid for this patient. J Yes. A section 1011 payment is generally not available for this patient. If checked, sign and date page 2. J No. Provide a reason why the patient is not eligible for Medicaid and go to question 2 below. Reason patient is not eligible for Medicaid: __________________________________________________ 2. Is the patient a Mexican citizen with a border-crossing card (i.e., laser visa, Form DSP-150) or has the patient been paroled into the United States at a United States port of entry with a Form I-94 that is stamped with term “Parole” or “Parolee”? J Yes. Attach a photocopy of the patient’s Form DSP-150 or I-94. The patient is potentially an eligible individual for section 1011 payment purposes. Skip question 3. Sign and date page 2. J No. Go to question 3 below. J Patient declines to answer or is unable to provide a copy of Form DSP-150 or I-94. Go to question 3 below. 3. The combination of a reported foreign place of birth and verification can be used as an affirmative demonstration of eligibility. Please check () any of the following that apply and attach a photocopy of any documentation obtained to establish payment eligibility. Providers must check at least one box and obtain verification in order to submit an individual payment request. J A foreign birth certificate, a foreign passport, a foreign voting card, an expired visa, a foreign driver’s license, a “Matricula Consular,” or other foreign identification card. J Submitted Social Security Number (SSN) is invalid or patient has never been issued a SSN. (Before checking () this box, the provider is required to verify and maintain evidence that the SSN is invalid.) J Federal or State officer/agent custody. Agency Name Agent Name/ID Form CMS-10130A (01/06) EF 02/2006 1 American LegalNet, Inc. www.USCourtForms.com NOTICE: I certify that the patient has been provided health care services as required by the application of section 1867 of the Social Security Act (42 U.S.C. 1395dd) and related services to achieve stabilization. I certify that, to the best of my knowledge and belief, the responses on this form accurately reflect the information that has been obtained with respect to this patient, and nothing I am aware of is inconsistent with a determination that the individual is an undocumented alien or an otherwise eligible alien under section 1011(c)(5). PROVIDER REPRESENTATIVE SIGN AND DATE Signature Date Name of Hospital Providing Emergency Care INSTRUCTIONS In determining a patient’s eligibility status, a provider is responsible for completing, signing, and dating this form and obtaining the documents to affirmatively determine patient eligibility. Enter the patient’s hospital medical record number and place of birth. A section 1011 payment is not available for individuals born in the United States. A provider should not ask a patient if he or she is an undocumented alien. However, if a patient voluntarily informs you that he or she is an undocumented alien, please check the box provided, sign, and date page 2. The patient is potentially an eligible individual for section 1011 payment purposes. QUESTION 1 Determine whether the patient is eligible for, or enrolled in, Medicaid or emergency Medicaid. If the patient is not eligible for Medicaid or emergency Medicaid, state the reason. If the patient is eligible for emergency Medicaid, a section 1011 payment may be available for emergency services not covered by emergency Medicaid. QUESTION 2 Enter the patient’s response to question 2. If the patient states that he or she is in the United States with a border-crossing card or has been paroled into the United States, copy and retain the patient’s Form DSP-150 or I-94. If the patient declines to answer or is unable to provide a copy of Form DSP-150 or I-94, a section 1011 payment may be available. Go to question 3. QUESTION 3 A provider may claim a section 1011 payment when a patient reports a foreign place of birth and the provider verifies eligibility in one of the following ways: FOREIGN DOCUMENTATION VERIFICATION: Patients reporting a foreign place of birth must submit one of the documents listed as proof of their eligibility. The provider must maintain verification information. SOCIAL SECURITY NUMBER VERIFICATION: Immigrants who are not legally able to obtain a Social Security Number are not required to have one. If the patient provides a Social Security Number voluntarily and it is determined to be invalid, the provider may check the “Submitted Social Security Number (SSN) is invalid” box. If the patient claims to have never been issued a SSN, the provider may check this box. If the patient claims to have a SSN, but does not recall or is unable to provide the number, this box may not be checked. While the Social Security Administration cannot validate Social Security Numbers for section 1011 payment purposes, providers may use their current practices and procedures or internal documentation to verify the authenticity of the Social Security Number provided. The provider must maintain verification information. FEDERAL OR STATE CUSTODY VERIFICATION: When a Federal or State officer or agent brings a patient into the emergency room, enter the name of the Federal or State Agency and the name and/or badge number of the officer or agent. Obtaining this information may not delay EMTALA screening and stabilization. RETENTION: Once complete, a provider must maintain this patient eligibility information. 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 0938-0952. The time required to complete this information collection is estimated to average 5 minutes 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 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 Officer, Baltimore, Maryland 21244-1850. Form CMS-10130A (01/06) EF 02/2006 American LegalNet, Inc. www.USCourtForms.com 2 OPTIONAL DISCLOSURE NOTICE Patients should be aware that the Department of Homeland Security will not access or use information related to medical care to initiate enforcement of United States immigration laws unrelated to an ongoing terrorism or criminal investigation. Form CMS-10130A (01/06) EF 02/2006 American LegalNet, Inc. www.USCourtForms.com 3