Medicare Secondary Payer (MSP) Worksheet

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Complete this form on all Medicare eligible patients even if Medicare is not being billed. Do this at admission and as appropriate during the course of care. Each organization should determine what department/staff will procure and retain needed information.

Other uses for this form are to monitor and evaluate trends regarding primary versus secondary payers, educate staff about primary versus secondary payers and educate patient and caregiver about Medicare as secondary payer.

Download a sample today!
8 1/2" x 11"
White paper 
Prints front and back different, 
Red and black ink
Padded in 100s.
More Information
MPN 3535P
Packaging 1 per each
Size 8 1/2In x 11In
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