Proof of Representation model language at a glance
What it is: Model language for Proof of Representation Liability Insurance (Including Self-Insurance), No-Fault Insurance, or Workers' Compensation.
Where and when to file: Submit Proof of Representation for Liability Insurance, No-Fault Insurance, Workers' Compensation to NGHP PO Box 138832 Oklahoma City, OK 73113.
Use the model language when you, the Medicare beneficiary, want to inform the Centers for Medicare & Medicaid Services (CMS) that you have given another individual the authority to represent you and act on your behalf with respect to your claim 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.
A filled-in Proof of Representation model language example: a son represents his mother
How to fill out Proof of Representation model language, box by box
Type of Medicare Beneficiary Representative
Check one of Individual other than an Attorney, Attorney, Guardian, Conservator or Power of Attorney, and then print the requested information.
Print the Name, Relationship to the Beneficiary, Firm or Company Name, Address, Address Line 2, City/State/ZIP and Telephone.
Medicare Beneficiary Information and Signature/Date
Under Medicare Beneficiary Information, print the Beneficiary's Name exactly as shown on your Medicare card, the Beneficiary's Medicare ID (number on your Medicare card) and the Date of Illness/Injury for which the beneficiary has filed a liability insurance, no-fault insurance, or Workers' Compensation claim.
The beneficiary signs at Beneficiary's Signature and enters the Date signed.
Representative Signature/Date
Your representative must also sign that he/she has agreed to represent you: Representative's Signature and Date signed.
More rules for Proof of Representation model language
Use of the model language is not required, but any documentation submitted as a Proof of Representation document must include the information the model language requests.
Proof of representation is required in order for the Benefits Coordination & Recovery Center (BCRC) to communicate with and provide information to a Medicare beneficiary's representative.
Please visit https://go.cms.gov/cobro for further instructions.
If your situation is different
You have an attorney
If you have an attorney, your attorney may be able to use his/her retainer agreement instead of this language.
The beneficiary is incapacitated
If the beneficiary is incapacitated, his/her guardian, conservator, power of attorney etc. will need to submit documentation other than this model language.
Common questions about Proof of Representation model language
Where do I file it?
Fax: (833) 844-1540.
Sources
[1] Proof of Representation model language, Centers for Medicare & Medicaid Services (the Official source link on this page).
