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Fillable MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE

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MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE Patient Name ___Integrated SMPT Acct # ___ Medicare # (exactly as on Red-White-Blue Government Medicare Card) ___ Please read and respond to each of the following: 1. Have you received Home Health Care of any kind in the past 60 days? Yes or NO If yes, please provide the name and phone number of the Home Health Agency: Home Health Agency Name: ___ Home Health Agency...
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