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