Medicare Consent to Release Form

Fill out
Export or Print
Download your fillable Medicare Consent to Release Form in  PDF
Create a free high quality Medicare Consent to Release form online now!

The medicare consent to release form can be described as a document that enables the beneficiary of the form to give necessary information to the center of Medicaid and Medicare service (also known as CMS). Also, this form allows the realization of personal medical information such as the history of injuries or illnesses, general medical conditions, and information on the payment and settlement of these conditions to a designated person. In other words, this form allows someone to have complete access to your medical information.

A designated person of this form can be anyone, a natural person, an attorney, legal entities like insurance companies, or a workers’ compensation carrier. The only requirement is the explicit desire of a beneficiary to send the information to this specific person. If a beneficiary would like to share medical information with more than one person, they must create a separate form for each of them.

Another important issue might arise in case if a beneficiary of the form is incapacitated, in such a case a person that acts on his or her behalf must provide a document that proves the legal capacity to do so.

Also, there is a possibility for a beneficiary of the form to revoke the completed form at any time by sending a special letter to the CMS.

How to create the form

Here is a small guide on how you can write this form by yourself.

First step

During the first step, you must carefully read the form in order to know what information you have to prepare.

Second step

At this phase, you can finally fill the boxes. Start from entering the information of the beneficiary, for this information the first blank space is designated.

Third step

Here you have to write down information about the receiving entity or person. The next information is necessary:

  • Name of the legal entity or person
  • Name of the contact person in case if the designated person is an entity
  • Full address
  • Telephone number
    Step 3 to filling out a medicare consent to release form personal info

Fourth step

At this stage, you must specify the time period during which CMS would be able to share your medical information. In the form, you can choose between one or two years options. However, there is also a possibility to write another period of time.
Step 4 to filling out a medicare consent to release form time period

Fifth step

During this step, you must provide information on the beneficiary of the form and his or her signature. The information needed is the date of signature, date of illness or injury, and medicare health insurance number.
Step 5 to filling out a medicare consent to release sample signature

When it’s needed

Usually, this form is used in cases when there is a need to relocate money from a worker compensation settlement in order to pay some medical benefits in the future. This money can be paid to cover expenses for treatment of any work-related illness or injury that otherwise could be paid by Medicare. Also, the law does not prohibit any workers from using this money for something else; however, in this case, all possible injuries and illnesses will be covered by their own funds.

In general, among the users of Medicare there exists a wide misconception about when to use consent to release and proof of representation, which is not great news because filing a wrong set of documents can significantly slow down the whole process.

Usually, these documents have almost identical appropriate content, and this fact only confuses people more. However, there is one important detail that makes distinguishing them easier, and this is the fact that proof of representation is needed when there are two layers of representation.

For example, when the worker is also represented by a lawyer or when the form is signed by a third person who was acting on behalf of a beneficiary.