Information To Help You Fill Out The Page 4

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4. Fill in the name and address of the person(s) or organization(s) to whom you want
Medicare to disclose your personal health information. Please provide the specific
name of the person(s) for any organization you list below:
Name:
1.
Address:
Name:
2.
Address:
Name:
3.
Address:
5.
I authorize 1-800-MEDICARE to disclose my personal health information listed
above to the person(s) or organization(s) I have named on this form. I
understand that my personal health information may be re-disclosed by the
person(s) or organization(s) and may no longer be protected by law.
Telephone Number
Date
Signature
(mm/dd/yyyy)
Print the address of the person with Medicare (Street Address, City, State, and ZIP)
Check here if you are signing as a personal representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney).
This only applies if someone other than the person with Medicare signed above.
Print the Personal Representative's Address (Street Address, City, State, and ZIP)
Telephone Number of Personal Representative:

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