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Good Samaritan Hospital Manual Outpatient Medicare Questionnaire

Medicare requires that the following questions be asked and answered for each date of any inpatient or outpatient service rendered. Failure to answer these questions and provide accurate information may result in a denial by Medicare to pay for any claim. Read each question carefully and answer by checking a yes or no in the appropriate box.

Both patient and spouse retirement dates are required. Disability dates for those recipients under the age of 65 and other possible insurance carriers. Renal patients please provide the start date for dialysis and answer the information in question 11.

Worker's Compensation claims with Medicare as your Medicare carrier answer question 6 below and all Medicare questions. If an automobile accident provide date of accident and auto insurance carriers name and address and answer question 8 and all Medicare questions.

Managed Care Health Maintenance Organizations require preauthorization and referrals in most cases. This is your responsibility to obtain prior to having services rendered. Our staff will coordinate the verification and authorization with your physician. A managed care form signed is necessary for all managed care carriers.

Patient's Signature:

If Yes, the name of your insurance, address, telephone number, member or policy number, social security number of member and the name and phone number of your primary physician.

Name of HMO: Phone:

Address:

Policy Number: Member:

Social Security Number:

Primary Care Physician:

Please Check Applicable Response

LOCATION OF PAIN:

Knee All Over Inside Front Outside Along prior scar Back

Hip Groin Buttocks Inside of Thigh Front of Thigh Outside of Thigh

Ankle All Over Outside Inside Top Bottom

Foot All Over Outside Inside Top Bottom

Leg All Over Outside Inside Thigh Calf

Shoulder Outside Inside Front Back

Hand All Over Fingers Palm Back

Wrist All Over Outside Inside Top

Please answer the following questions.

If you do not know the answer, write in D.K. for don't know.

What is the highest dose of steroids you have ever taken?

How long did you take this dose?

Why were you prescribed steroids?

VITAMINS/SUPPLEMENTS:
Please list all vitamins, minerals and supplements you take on a routine basis.

ACTIVITIES:
(Please indicate applicable response)

1 = Currently able to do

2 = Cannot currently do, but would like to be able to do

1 2 Carrying	1 2 Lifting	1 2 Stooping	1 2 Stairs
1 2 Skiing	1 2 Golf	1 2 Tennis
Other:

MAJOR JOINT SURGERY

Joint	Procedure	Helpful	Complications during or after surgery

Joint Injections: No Yes     HELPFUL         NOT HELPFUL

If Yes, how many and how long have you been receiving them

Approximately how long since your last injection

GENERAL HEALTH: Excellent Good Fair Poor

HEAD Headaches History of Accidents

NECK Stiffness Pain Arthritis Thyroid Problem

SKIN Infections Boils Psoriasis

EYES

Glasses	Cataract	Cataract Surgery	Pain	Legally Blind
Yes No	Right Left	Right Left	Right Left	Right Left

EARS

Hearing Loss	Hearing Aid	Ringing/Buzzing	Infection
Right Left	Right Left	Right Left	Right Left

NOSE/THROAT Bleeding Hoarseness Polyps Sinus Problems Trouble Swallowing

RESPIRATORY Asthma Wheezing Chronic Cough Shortness of Breath
Coughing up Blood Pain on Breathing