Informed Consent Form


My attorney has informed me that because I received a personal injury settlement and
receive Medicare health insurance benefits, Medicare may not pay for my future medical
expenses related to my injury.
I understand that the cost of my future medical treatment may be my responsibility, and
Medicare may not pay those expenses. I understand this even though Medicare will pay other
medical expenses not related to my injury. I also understand that since this condition may be
considered pre-existing, it is unlikely that any private health care company will insure me for
health benefits related to this injury.
I understand that Medicare may require that I pay for any Medicare covered expenses
from the proceeds of this settlement for future medical expenses related to my injury. My
attorney has further advised me of this and has allocated a portion of my settlement to pay for my
future medical expenses related to my injury that Medicare would pay for including prescription
drug coverage. My attorney has advised me that I need to make appropriate arrangements to
ensure that I will have funds available from the proceeds of this settlement to pay any future
medical expenses that may arise as a result of this injury.
I have further been advised that it is my responsibility to self administer my own account,
to only pay for Medicare covered medical expenses from such account, and to maintain written
documentation of amounts paid from such account.
I understand that there is some risk involved and I elect to proceed and settle my personal
injury claim, knowing of the possible adverse effect on my Medicare benefits.
I have read the above and have had it explained to me by my attorney in the presence of a
witness of my choice who acknowledges that the same was done in his or her presence on the
undersigned date.
Attorney at Law


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