DECLARATION –MEDICARE BENEFICIARY STATUS

The Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (the MMSEA) (See 42 U.S.C. 1395y(b)(7)&(b)(8)), requires liability insurance companies to report settlements, judgments, awards, or other payments made to Medicare Beneficiaries regardless of whether or not there is a determination or admission of liability. 

I, _________________, being of lawful age, hereby declare and represent that:

________ Patient Name is/was a Medicare Beneficiary because:

a)      Patient Name receives/did receive health insurance coverage through Medicare whether it be Medicare Part A – Hospital Insurance, Medicare Part B – Medical Insurance, Medicare Part C – Medicare Advantage Plan Coverage or Medicare Part D – Prescription Drug Coverage AND/OR

b)      Patient Name receives/did receive Medicare benefits because of certain disabilities (as defined by Medicare) or End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). 

I, _________________, being of lawful age, hereby declare and represent that:

________ Patient Name is not/was not a Medicare Beneficiary because:

a)      Patient Name does not/did not receive health insurance coverage through Medicare in any form whether it be Medicare Part A – Hospital Insurance, Medicare Part B – Medical Insurance, Medicare Part C – Medicare Advantage Plan Coverage or Medicare Part D – Prescription Drug Coverage AND/OR

b)      Patient Name does not/did not receive Medicare benefits because of certain disabilities (as defined by Medicare) or End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). 

This document is being signed in conjunction with the Settlement Release. 

I have carefully read the foregoing and represent the same to be true and correct to the best of my knowledge and belief.

  Date: ____________________                               ________________________________

                                                                                    Patient’s Name or Person Acting on Behalf

                                                                                    of Patient

                                                                                    _________________________________

                                                                                    Relationship to Patient

STATE OF__________________      )

                                                            )ss.

COUNTY OF _______________      )

            SUBSCRIBED AND SWORN to before me by Patient’s Name or Person Acting on Behalf of Patient this ______ day of ____________ 2010.

            My commission expires:

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