Consent To Release Form
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1CONSENT TO RELEASE FORM
I, __________________ hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents
and/or contractors to release, upon request, information related to my injury/illness and/or settlement to the
individual(s) and/or firm(s) listed below:
PLEASE CHECK:
Claimant’s attorney
___________________________________
(Name and/or firm)
Insurance carrier
___________________________________
(Name and/or company)
Other ________________
___________________________________
(Explain)
(Name and/or firm)
How long can we give out the information? (Check one Block)
Ongoing, beginning _____________________
Month/Date/Year
Limited time ______________________ through _________________
Month/Date/Year
Month/Date/Year
One time only
_____________________________________
_______________________
Claimant’s Signature
Date Signed
_______________________
_______________________
Date of Injury
Medicare Number
If your Power of Attorney (POA) or legal representative signs this form for you, a copy of their POA or
representation papers must be sent to us with this form.
Completion and signing of this consent form:
Authorizes release of information to the person named above upon their request. This means that
information disclosed to the above named person may be re-disclosed by them and may no longer be
protected by law.
Allows release of Medicare claims and other information related to your injury/illness.
Is for release of information purposes only and does not affect benefits you are entitled to under the
Medicare Program.
You have the right to revoke your authorization at any time in writing, except to the extent that CMS has
already acted based on your permission. To revoke, send a written request to the address below.
Medicare Secondary Payer Contractor
PO Box 33828, Detroit MI 48232-3828
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