Cms/medicare Authorization For Release Of Information printable pdf download

Cms/medicare Authorization For Release Of Information

CMS/Medicare Authorization for Release of Information

The Privacy Act of 1974 (Public Law 93-579) prohibits the government from revealing

information from personal files without the express written permission of the person

involved. Disclosure of personal records to an attorney or other representative who is

acting on behalf of another person is prohibited, unless the individual to whom the record

pertains has consented.

I, _________________________, hereby authorize the Centers for Medicare & Medicaid

Services (CMS), its agents and/or contractors to disclose, discuss, and/or release, orally

or in writing, information related to my accident, injury and/or settlement to the

individual(s) and/or firm(s) listed below. I also hereby authorize the individual(s) or

firm(s) listed below to disclose, discuss, and/or release, orally or in writing, information

needed to negotiate conditional payments with the CMS. I also hereby authorize

NuQuest to register me under the "myMedicare.gov" website to obtain from said

website conditional payment information related to my workers' compensation claim. I

also hereby authorize NuQuest to release my current treatment and pharmacy

records to CMS for the purposes of negotiating conditional payments and for the

purpose of obtaining CMS approval of a MSA proposal. This authorization for

release is for my current accident, injury, or claim and is on an ongoing basis.

An additional consent to release form will not be necessary unless or until I revoke

this authorization (which must be in writing).

PLEASE CHECK:

Claimant’s attorney

(name and/or firm)

Employer’s attorney

(name and/or firm)

Other

(name and/or firm)

MSA Vendor

NuQuest

(name and/or firm)

Claimant’s Signature

Date Signed

____________________

___________

__________

Date of Injury

Social Security Number or Health

Insurance Claim Number

*This Consent to Release form is valid for two years from date of signature.

Cms/medicare Authorization For Release Of Information