Form CMS-10902 Environmental Health Hazards Checklist (English)

Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-XXXX

CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: XX/XX

Environmental Health Hazards Checklist

Medicare Coverage for Individuals Exposed to Environmental Health Hazards

Step 1: Identify the individual (Completed by the field office)
First name	Middle initial	Last name
Social Security Number (SSN)		Date of birth (mm/dd/yyyy)

Step 2: Identify the asbestos-related condition(s) and date of diagnosis

(Completed by the provider)

Check the box next to the diagnosed impairment(s) and print the date of diagnosis.

Impairment	Diagnosis Code	Minimum Medical Evidence Required
Asbestosis	5010	Interpretation by a B reader qualified physician of a plain chest x-ray or interpretation of computed tomographic radiograph of the chest by a qualified physician
Pleural thickening Pleural plaques	5010	Interpretation by a B reader qualified physician of a plain chest x-ray or interpretation of computed tomographic radiograph of the chest by a qualified physician
Mesothelioma	1630	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the lung	1620	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the colon	1530	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the rectum	1530	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the larynx	1950	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the stomach	1510	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the esophagus	1500	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the pharynx	1950	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage
Malignancy of the ovary	1830	Established by pathologic examination of biopsy tissue or cytology from bronchioalveolar lavage

Form CMS-XXXXX (XX/XX) 1

Step 3: Identify presence in Lincoln County, Montana

(Completed by the provider)

Do your records dated prior to March 23, 2010, indicate the individual was present in Lincoln County, Montana, for a total of at least 6 months during a period ending 10 years or more before the date of his or her diagnosis of the impairment(s) checked above?

I understand that anyone who, knowingly and willfully — (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or (2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined or imprisoned not more than 5 years, or both.

Printed name
Physician’s signature	Date (mm/dd/yyyy)

Paperwork Reduction Act: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. This information collection is necessary to determine your eligibility for Medicare coverage, to comply with federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the Veterans Administration), and to assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs (like to the Bureau of the Census and contractors of Social Security and CMS). The time required to complete this information collection is estimated to average less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required in order to determine eligibility for Medicare coverage for individuals exposed to environmental health hazards. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS-XXXXX (XX/XX) 2