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* MM slash DD slash YYYY 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* MM slash DD slash YYYY Print Guardian's/Fiduciary's Name and Relationship to Resident* Guardian/Fiduciary's Signature*Date* MM slash DD slash YYYY Share this:FacebookTwitterLinkedIn
