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Medicare Secondary Payer (MSP) Worksheet

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Updated form effective December 7, 2020  (CMS updated/streamlined from previous versions)


Providers are required to determine whether Medicare is a primary or secondary payer for every admission of a Medicare beneficiary as well as an outpatient encounter with a Medicare beneficiary prior to submitting a bill to Medicare. 

This worksheet identifies the questions that should be asked for every admission, outpatient encounter or start of care with exceptions provided. 


This form is available in paper as well as digital format.


Download a sample today!

• 8 1/2" x 11"
• White paper 
• Prints 2-sides;  front and back different 
• Red and black ink
• 100 per pad

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