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REQUEST FOR MEDICARE PAYMENT

Form Approved
OMB NO
72-RO730

MEDICAL INSURANCE BENEFITS-SOCIAL SECURITY ACT (See Instructions on Back-Type or Print Information)
NOTICE-Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal Law.
PART I-PATIENT TO FILL IN ITEMS 1 THROUGH 6 ONLY

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HOW TO FILL OUT YOUR MEDICARE FORM

There are two ways that Medicare can help pay your doctor bills

One way is for Medicare to pay your doctor.-If you and your doctor agree, Medicare will pay him directly. This is the assign. ment method. You do not submit any claim; the doctor does. All you do is fill out Part I of this form and leave it with your doctor. Under this method the doctor agrees to accept the charge deter mination of the Medicare carrier as the full charge; you are responsible for the deductible and coinsurance. Please read Your Medicare Handbook to help you understand about the deductible and coinsurance. (Because Medicare has special payment ar rangements with group practice prepayment plans these plans handle all claims for covered services they furnish to their members.)

The other way is for Medicare to pay you.-Medicare can also pay you directly-before or after you have paid your doctor. If you

submit the claim yourself, fill out Part I and ask your doctor to fill out Part II. If you have an itemized bill from him, you may submit it rather than have him complete Part II. (This form, with Part I completed by you, may be used to send in several itemized bills from different doctors and suppliers.) Bills should show who furnished the services, the patient's name and number, dates of services, where the services were furnished, a description of the services, and charges for each separate service. It is helpful if the diagnosis is also shown. Then mail itemized bills and this form to the address shown in the upper left-hand corner. If no address is shown there, use the address listed in Your Medicare Handbook-or get advice from any social security office.

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Final Report of the Medicare Project

National Academy
of

Public Administration

The National Academy of Public Administration is an independent organization devoted to nonpartisan research, education, and publication in the field of public administration. Its principal purposes are to serve as a source of advice and counsel to governments and public officials on problems of public administration; to help improve the policies, processes, and institutions of public administration through early identification of important problems and significant trends; to evaluate program performance and administrative progress; and to increase public understanding of public administration and its critical role in the advancement of a democratic society. In attempting to achieve these goals, the Academy draws upon administrators, scholars, and other persons in public affairs in the study of problems, the evaluation of performance, and the anticipation of significant developments.

In publishing studies, the Academy presents them as competent treatments of a subject warranting public consideration. The findings and conclusions of this study are those of the Medicare Project Panel and assisting staff. They do not necessarily represent the views of other staff associates, Academy members, officers, or Trustees of the Academy.

Roy W. Crawley
President

National Academy

of

Public Administration

Foundation

June 30, 1973

Mr. Arthur E. Hess

Acting Commissioner of Social Security

Department of Health, Education, and Welfare

Room 4700 HEW North Building

330 Independence Ave., S.W.

Washington, D.C. 20201

Dear Mr. Hess:

We are pleased to submit for your consideration the Final Report of the Medicare Project Panel. We also have included a list of the Panel members and Academy staff who have been associated with the project as well as a copy of the charter under which the Panel operated.

During the past two years, the Panel has been involved in a number of projects, including management information systems, the role of on-site representatives, an experiment designed to develop a more effective means of utilizing contractors in collecting statistical data, and an analysis of relationships between the Bureau of Health Insurance and the Office of Research and Statistics. The first Annual Report to the Commissioner of Social Security, April 30, 1973, described these activities in some detail.

The Panel also sponsored the Belmont Conference on the Administration of Medicare and has published the summary of those proceedings and a compendium of the papers prepared for that conference: Summary of the Proceedings of the Belmont Conference and The Administration of Medicare: A Shared Responsibility.

Although the Panel's accomplishments did not match its expectations, we trust that its efforts have made a contribution to the Social Security Administration and its Medicare contractors in improving the administration of the Medicare Program.

We believe it will be helpful to the National Academy of Public Administration, and perhaps also to the Social Security Administration, to review briefly the history of the evolution of the Medicare Panel. The contract between the two parties took about a year to negotiate and was unusual in its terms. Essentially it contemplated a specific application of the Academy's role as a trusted advisor in public management.

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