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 "" 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).
Claimant’s attorney
(name and/or firm)
Employer’s attorney
(name and/or firm)
(name and/or firm)
MSA Vendor
(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.


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Parent category: Medical