Medicare Primary, Medicare Supplement Secondary

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Today's Date*
MM slash DD slash YYYY
Patient Name*
First Last
Hidden
Phone*
Hidden
Email*
Clinic*
Medicare is Primary
Clinic’s Participation Status
- Participating provider with Medicare
- Non-participating provider with Medicare
Medicare Deductible
Medicare Deductible
How much deductible left to meet for this year?
Medicare Supplement Plan is Secondary
Does this plan cover the patient’s Medicare Part B deductible?
- Yes
- No
Does this plan cover the patient’s Medicare Part B co-pay?
- Yes
- No
Additional Information
Does this plan cover the patient’s Medicare Part B deductible? Patient pays clinic in full for charges. Medicare supplement plan normally sends payment to patient.

Does this plan cover the patient’s Medicare Part B co-insurance? Patient pays clinic in full for charges. Medicare supplement plan normally sends payment to patient.
Co-pay for spinal manipulation
Co-pay for spinal manipulation
Does this supplement plan follow the Wisconsin State Mandate?
- Yes
- No
Additional Information
- Exams/re-exams - paid in full by Medicare Supplement Plan.
- X-rays - paid in full by Medicare Supplement Plan.
- Therapies - paid in full by Medicare Supplement Plan.
- Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long.
- Pre-authorization - not required.
Additional Information
- Exams/re-exams - paid in full by Medicare Supplement Plan. Medicare supplement plan normally sends payment to patient.
- X-rays - paid in full by Medicare Supplement Plan. Medicare supplement plan normally sends payment to patient.
- Therapies - paid in full by Medicare Supplement Plan. Medicare supplement plan normally sends payment to patient.
- Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long.
- Pre-authorization - not required.
Additional Information
- Exams/re-exams - not covered by Medicare or Medicare Supplement Plan (but recommended to do on first visit of new diagnosis). Patient responsibility.
- X-rays - not covered by Medicare or Medicare Supplement Plan. Patient responsibility.
- Therapies - not covered by Medicare or Medicare Supplement Plan. Patient responsibility.
- Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long.
- Pre-authorization - not required.
Additional Comments
Disclaimer
When we call on a patient's insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact chiropractic benefits.
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Medicare Primary, Medicare Supplement Secondary

Medicare is Primary

Medicare Supplement Plan is Secondary