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MEDICARE SCREENING FORM

FACILITY NAME: __________________________________________

RESIDENT LAST NAME: ____________________________________

RESIDENT FIRST NAME: ____________________________________

DATE OF BIRTH: _________________________

SOCIAL SECURITY NUMBER: ___________________________________

MEDICARE NUMBER: __________________________________________

Male: ____  Female: ____

PLEASE COMPLETE THIS FORM PRIOR TO ACCEPTING THE RESIDENT AND FAX IT TO: (727) 723-3076

PLEASE WRITE THE FAX NUMBER YOU WANT THE MEDICARE PART A DAYS LEFT REPLY FAXED BACK TO: __________________________.