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Exhibit 5 Patient Name: Patient ID Number: Physician:DEPARTMENT OF HEALTH & HUMAN SERVICESCenters for Medicare & Medicaid Services OMB Approval No. 09380692AN IMPORTANT MESSAGE FROM MEDICARE ABOUT
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What is patient name?
Patient name is the name of the individual receiving medical treatment.
Who is required to file patient name?
Healthcare providers are required to file patient names.
How to fill out patient name?
Patient names should be filled out accurately and completely in the designated fields on medical forms.
What is the purpose of patient name?
The purpose of patient name is to identify the individual receiving medical care.
What information must be reported on patient name?
Patient name should include first name, last name, and any other relevant identifying information.
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