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The Centers for Medicare & Medicaid Services (CMS) is the federal agency that 

oversees the Medicare program. Many Medicare beneficiaries have other private 

group health plan (GHP) insurance in addition to their Medicare benefits. There are 

federal rules that determine whether Medicare or the other GHP insurance pays first. 

Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), 

a new federal law that became effective January 1, 2009, requires that group health 

insurance plans, certain claims processing third- party administrators, and certain 

employer self-funded/self-administered plans report specific information about 

Medicare beneficiaries who have other group coverage. This reporting is to assist 

CMS and other health insurance plans to properly coordinate payment of benefits 

among plans so that your claims are paid promptly and correctly. 

We are asking you to the answer the questions below so that we may comply with this 

law. 

Please review the picture of the Medicare card below to determine if you, a spouse, 

or other family members covered by your group health plan have, or has ever had, a 

similar Medicare card: 

Section I

Are you presently, or have you ever been, enrolled in Medicare Part A or Part B? 

 YES NO 

If yes, please complete the following. If no, proceed to Section II. 

Full Name:

(Please print the name exactly as it appears on your SSN or Medicare card if available.) 

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 
Section II

Do you have a spouse that is presently, or has ever been, enrolled in Medicare Part A or 

Part B? 

 YES NO 

If yes, please complete the following. If no, proceed to Section III. 

Full Name:

(Please print the name exactly as it appears on the SSN or Medicare card if available.) 

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 

Section III

Do you have another covered family member that is presently, or has ever been, enrolled 

in Medicare Part A or Part B? 

 YES NO 

If yes, please complete the following. If no, proceed to Section IV. If additional space is 

needed for completion of this section, please attach another sheet. 

Full Name:

(Please print the name exactly as it appears on the SSN or Medicare card if available.)

Relationship:

(Dependent child, domestic partner, other.) 

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 

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Full Name:

(Please print the name exactly as it appears on the SSN or Medicare card if available.)

Relationship:

(Dependent child, domestic partner, other)

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 

Full Name:

(Please print the name exactly as it appears on the SSN or Medicare card if available.)

Relationship:

(Dependent child, parent, domestic partner, etc.) 

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 

Full Name:

(Please print the name exactly as it appears on the SSN or Medicare card if available.)

Relationship:

(Dependent child, parent, domestic partner, etc.) 

Medicare Claim Number:

Date of Birth:

Sex:

Social Security Number:

(If Medicare Claim Number is Unavailable) 

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Section IV

I understand that the information requested is to assist my insurer, third party 

administrator or group health plan to accurately coordinate benefits with Medicare and to 

meet its mandatory reporting obligations under Medicare law. 

______________________________________________________ 

Subscriber Name (Please Print) 

____________________________________ 

Subscriber’s Plan ID 

______________________________________________________ 

Name of Person Providing This Information (Please Print) 

_______________________________________________________ 

Signature of Person Completing this Form 

_________________________ 

Date 

If you have completed Sections I – IV above, stop here. If you are refusing to provide the 

information requested in Sections I – IV, proceed to Section V. 

Section V

_______________________________________________________ 

Subscriber Name (Please Print) 

_______________________________________________________ 

Subscriber’s Plan ID 

For the reason(s) listed below, I have not provided the information requested. I 

understand that if I am a Medicare beneficiary and I do not provide the requested 

information, I may be violating obligations as a beneficiary to assist Medicare in 

coordinating benefits to pay my claims correctly and promptly 

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Reason(s) for Refusal to Provide Requested Information: 
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_____________________________________________________________ 

Name of Individual Providing This Information (Please Print) 

_____________________________________________________________ 

Signature of Individual Providing This Information 

_________________________ 

Date