AFFIDAVIT REGARDING MEDICARE BENEFITS



AFFIDAVIT REGARDING MEDICARE BENEFITS

STATE OF__________

COUNTY OF _____________

BEFORE ME, the undersigned authority, personally came and appeared, __________, who, first being duly sworn, did depose and says that:

1. He/She was an Employee of

2. He/She has made a claim for workers' compensation benefits and has been paid

workers' compensation benefits by the insurance carrier for__________

3. He/She is not eligible for, nor has he applied for, nor is he receiving, nor has he in the past received Social Security Disability Income (SSDI) or Medicare benefits,

4. He/She has not received benefits relating to his/her injury of_________, from

SSDI, Medicare, or any other collateral source including, but not limited to, individual or group health insurance benefits and medical benefits provided to veterans of the United States military.

5. He/She does not reasonably expect the receipt of benefits from SSDI, Medicare, or any other collateral source related to his/her injury of ________________

6. He/She asserts that the purpose of this settlement is not to shift responsibility for payment of medical expenses resulting from the alleged work injury to Medicare.

7. He/She understands that Employer,_____________________, has

relied on this information in consideration of the settlement of his/her claim.

FURTHER AFFIANT SAYETH NOT.

CLAIMANT

SWORN TO AND SUBSCRIBED, before me this_____ day_______ of 20xx.

NOTARY PUBLIC

IN AN FOR THE STATE OF

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