Intake Forms- RESIDENT CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST July 18, 2011 By Maunalani Staff Identifying Other Primary Payers During the Admission ProcessResident Name* First Last Admission Date* Part 1Was illness/injury due to a work-related accident/condition and covered by a worker's compensation plan or the Federal Black Lung Program?* Yes No Name and address of worker's compensation plan or Federal Black Lung ProgramPart 2Was illness/injury due to a nonwork related accident?* Yes No What type of accident caused illness/injury?Name and address of insurerInsurance Claim No.Part 3Is the patient aged 65 or over?* Yes No Is the patient undergoing kidney dialysis for End Stage Renal Disease (ESRD)?* Yes No Is the patient employed and covered by the Employer's Group Health Plan?* Yes No Name and address of EGPPatient's Identification No.Is the patient's spouse employed?* Yes No Is the patient covered under the group health plan of the spouse's employer?* Yes No Name and address of EGPPatient's Identification No.Part 4Is the patient entitled to benefits solely on the basis of ESRD?* Yes No Is the patient covered by an EGHP?* Yes No Name and address of EGPPatient's Identification No.Has the patient been undergoing kidney dialysis for more than 18 months or been entitled to Medicare for more than 18 months?* Yes No Is the patient within an 18-month period as defined in §1862(B)(1)(C) of the Act?* Yes No Resident's Signature*Date* Print Guardian's/Fiduciary's Name and Relationship to Resident*Guardian/Fiduciary's Signature*Date*
