I ,   First Name   Last Name , hereby authorize the Medicare Consent to Release, its agents and/or contractors to release, upon request, information related to my injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed below:

CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION AND THEN PRINT THE REQUESTED INFORMATION:

Insurance Company Workers' Compensation Carrier  Other  

    Explain if select other.    

Name of Entity:   First Name   Last Name   

Contact for above entity:   Area Code   Phone Number  

 

Address:   Street Address      City   State   Zip   

Phone Number:   Area Code   Phone Number   

CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR INFORMATION.

One Year Two Years   Other   Explain if select other.    

Beneficiary Signature:   Signature   

Date Signed:   Date   

Medicare Health Insurance Card Number:   123456789  

Date of Injury/Illness: Date