Proof Of Representation
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1PROOF OF REPRESENTATION
The undersigned Medicare beneficiary informs the Centers for Medicare & Medicaid Services (CMS) that they
have given the specified legal representative the authority to represent them and act on their behalf with respect
to any claims for liability insurance, no-fault insurance, or workers compensation, including releasing identifiable
health information or resolving any potential recovery claim that Medicare may have if there is a settlement,
judgment, award, or other payment. The undersigned representative agrees that they represent the stated
Medicare beneficiary.
Type of Representative:
Authorized Representative:
(
) Individual other than an Attorney:
______________________________________________
( X ) Attorney
(Attorney/ Law Firm Name)
(
) Guardian*
(
) Conservator*
______________________________________________
(
) Power of Attorney*
(Law Firm Address)
______________________________________________
(Law Firm City, State, Zip)
______________________________________________
(Phone Number)
* If the beneficiary is incapacitated, his/her guardian, conservator, power of attorney etc. will need to submit
documentation in addition to this proof of representation.
Medicare Beneficiary Information:
Beneficiary’s Name
(please print exactly as shown on your Medicare card):
__________________________________
Beneficiary’s Health Insurance Claim Number
(number on Medicare card):
__________________________________
Date of Illness/Injury for which the beneficiary has filed a
liability insurance, no-fault insurance or workers’
compensation claim:
__________________________________
Beneficiary’s Signature: __________________________________
Date signed: ___________________
Representative’s Signature: _______________________________
Date signed: ___________________
(Attorney)
GRG-2011
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Parent category: Medical