Medicare Beneficiary Information printable pdf download

Medicare Beneficiary Information

Beneficiary’s Name ________________________________________________________________________

(Exactly as shown on Medicare Card)

Beneficiary’s HICN: ___________________________________

Date of Injury: ______________________

Proof of Representation

Levinson Axelrod, P.A. represents the above listed Medicare Beneficiary and is authorized to obtain any and all

records/information from CMS, its agents and/or contractors.

Type of Medicare Beneficiary Representative: (x) Attorney

Attorney Name: _____________________________________

Law Firm: Levinson Axelrod, P.A.

□ 2 Lincoln Highway, P.O. Box 2905, Edison, NJ 08840

732-494-2727

□ 274 Church Street, Belford, NJ 07718

732-787-3200

□ 124 Route 31, Flemington, NJ 08822

908-782-6766

□ 654 Lacey Road, Forked River, NJ 08731

609-971-1177

□ 302 Route 206, Hillsborough, NJ 08844

908-359-0110

□ 3641 Route 9 North, Howell, NJ 07731

732-730-9600

□ 220 Forsgate Drive, Jamesburg, NJ 08831

732-656-3650

Consent to Release

I, __________________________________________________, hereby authorize the CMS, its agents and/or

contractors to release, upon request, information related to my injury and/or settlement for the specified date of

injury to the attorney and law firm listed in the above “Proof of Representation.”

The information can be provided on an ongoing basis, from the date of the signature appearing on this form.

I understand that I may revoke this “consent to release information” at any time, in writing.

Medicare Beneficiary Signature

Client’s Signature: ______________________________________

Date: ________________________

Representative’s Signature: _______________________________

Date: ________________________

Return to: NGHP, P.O. Box 138832, Oklahoma City, OK 73113; Fax: 405-869-3309

Medicare Beneficiary Information