Proof Of Representation PDF Details

As a citizen of the United States, you have the right to vote. This is a right that many people take for granted, and it is one that should be exercised. One way to ensure that your vote is counted is by using a Proof Of Representation Form. This form can be used to verify that you are authorized to vote in a particular election. There are several reasons why you may need to provide proof of representation, including: voting from outside your home state, voting in a presidential election as a delegate, or voting as an absentee voter. No matter what the reason, using a Proof Of Representation Form is the best way to ensure that your vote will be counted.

These are some facts you may want to analyze before starting dealing with the proof of representation.

QuestionAnswer
Form NameProof Of Representation
Form Length15 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 45 sec
Other namesmedicare proof of rep form, medicare letter of representation, cms proof of representation form, medicare proof of representation

Form Preview Example

“Proof of Representation” vs. “Consent to Release”

WHO SHOULD READ THIS DOCUMENT?

If you are a beneficiary and have a representative, please read the information in the “Rights and Responsibilities Letter” and “Rights and Responsibilities Brochure” which explain what documentation is needed or go directly to the information provided in the “Proof of Representation Model Language” document.

If you represent the beneficiary, please read this document so that

you understand what you need for proper proof of representation

(vs. the ability to only receive certain information through a “consent to release” document).

If you do not represent the beneficiary but want to request

information regarding the beneficiary, please read this document so that you will understand what a “consent to release” document is as well as when and how it is used.

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Rules and Model Language

for

“Proof of Representation” vs. “Consent to Release”

for

Medicare Secondary Payer

Liability Insurance (Including Self-Insurance),

No-Fault Insurance, or Workers’ Compensation

2

General

Pursuant to the Privacy Act, Medicare does not release information from a beneficiary’s records without appropriate authorization to do so.

For beneficiaries who have filed a claim for liability insurance (including self-insurance), no-fault insurance, or workers’

compensation, this typically means that the MSPRC will receive either a “proof of representation” document signed by the beneficiary and the beneficiary’s representative or a “consent to release” document signed by the beneficiary. (See page 12. Medicare may

provide conditional payment information to no-fault insurers or workers’ compensation carriers without a “consent to release” document.)

3

“Consent to Release” vs. “Proof of Representation” –

What’s the Difference?

Proof of Representation -- The beneficiary has authorized the individual or entity (including an attorney) to act on the beneficiary’s behalf. The representative has no independent standing, but may receive or submit information/requests on behalf of the beneficiary, including responding to requests from the MSPRC, receiving a copy of the recovery demand letter if Medicare has a recovery claim, and

filing an appeal (if appropriate) when that beneficiary is involved in a liability, workers’ compensation, or auto/no-fault situation.

Under these circumstances, the exchange of information is a two way street. The individual or entity may provide necessary

information to or interact with the MSPRC, on behalf of the beneficiary, in order to resolve Medicare’s Recovery Claim.

4

“Consent to Release” vs. “Proof of Representation” –

What’s the Difference?

Consent to ReleaseThe beneficiary has authorized an individual or entity to receive certain information from the MSPRC for a limited period of time. The release does not give the individual or entity the authority to act on behalf of the beneficiary.

Under these circumstances, the exchange of information is a one- way street. The beneficiary has authorized the MSPRC to provide privacy protected data to the specified individual/entity, BUT this does not authorize the individual/entity requesting information to act on behalf of/make decisions on behalf of the beneficiary.

5

Proof of Representation –

What is required?

The following pages will address:

Beneficiary non-attorney representatives.

Beneficiary attorney representatives ( including third part lien negotiation entities).

Beneficiary guardians, conservators, power of attorney, Medicare representative payees.

Situations where the beneficiary’s representative (representative payee, conservator, guardian, power of attorney) has hired an attorney or the beneficiary attorney has referred the case to another attorney.

Deceased beneficiaries.

Workers’ Compensation or No-Fault Insurance vs. Liability Insurance (Including Self-Insurance).

Agents for insurers or workers’ compensation carriers.

6

Proof of Representation –

What is required? (continued)

Beneficiary non-attorney representatives.

1.The beneficiary must:

Provide his/her name as shown on his/her Medicare card,

Provide his/her Medicare Health Insurance Claim Number (HICN)(the number on the Medicare card),

Appoint the representative in writing,

Specify the following information for the representative: name, type of representative, firm/company name (if applicable), address, telephone number,

Sign and date the appointment,

2.The representative must sign and date the document to show that he/she has agreed to represent the beneficiary.

7

Proof of Representation –

What is required? (continued)

Beneficiary attorney representatives may submit their retainer

agreement with the beneficiary if:

The retainer agreement is on attorney letterhead or accompanied by a cover note on letterhead,

The retainer agreement is signed by the beneficiary,

The beneficiary’s name and Medicare Health Insurance Claim

Number (HICN) are printed at the top of the form (this may be added after the retainer agreement is signed), and

The retainer agreement is signed or countersigned and dated by the attorney.

Beneficiary attorneys may also provide the same proof of representation as non-attorneys if they wish to do so.

8

Proof of Representation –

What is required? (continued)

Beneficiary guardians, conservators, power of attorney, Medicare representative payees.

Guardian or Conservator -Submit proper court documents for status as a guardian or conservator.

Power of Attorney -Submit power of attorney documents for power of attorney status if the beneficiary is incompetent you must have a durable power of attorney.

Representative Payee Notify the MSPRC if you are the

representative payee for the Medicare beneficiary, and the MSPRC will verify this status within CMS’ systems.

9

Proof of Representation –

What is required? (continued)

Situations where the beneficiary’s representative (representative payee,

conservator, guardian, power of attorney) has hired an attorney or the beneficiary’s attorney has referred the case to another attorney

Beneficiary’s representative has hired an attorney -- The attorney must

submit both the necessary proof of representation document or retainer agreement from the beneficiary’s representative and the documentation required from representative payees, conservators, guardians, power of attorney.

Beneficiary attorney refers a matter to another attorneyThe second

attorney must have a letter from the first attorney showing his/her association on the beneficiary’s claim and the necessary proof of representation document or retainer agreement from the beneficiary to the first attorney.

In other words, you must have an appropriate chain of authorization. We need

to be able to link the beneficiary to you.

10

 

Proof of Representation –

What is required? (continued)

Deceased beneficiaries

If a beneficiary is deceased before resolution of a Medicare

secondary payer recovery claim associated with a liability insurance (including self-insurance), no-fault insurance or workers’

compensation settlement, judgment, award, or other payment, new proof of representation on behalf of the beneficiary’s estate must be submitted. If there is no will or formal estate, the document or documents must be signed by an individual who is entitled under state law to pursue the applicable claim.

Where state law requires court documentation to establish such status, provide that documentation. Where no such state requirement exists, and a will is available, provide the initial page of the will, the page(s) showing the executor, and the notarized signature page(s).

11

Proof of Representation –

What is required? (continued)

Workers’ Compensation or No-Fault Insurance vs. Liability Insurance (Including Self-Insurance)

The MSPRC will provide conditional payment information to a workers’ compensation entity/carrier or no-fault insurer without a consent to release document.

The MSPRC will not provide conditional payment information to a liability insurer (including self-insurance) without a proper consent to release document. (This includes any attempt to request such information through a Freedom of Information Act (FOIA) request.)

12

Proof of Representation –

What is required? (continued)

Agents for insurers or workers’ compensation carriers–

Agents must have a beneficiary specific statement (including the beneficiary’s name and HICN) on the insurer or workers’ compensation entity’s letterhead that the agent is representing the insurer or workers’ compensation carrier with respect to a claim involving the identified Medicare beneficiary.

The MSPRC will routinely provide a conditional payment letter (CPL) to the no-fault insurer or workers’ compensation entity/carrier as

soon as the conditional payment information is available if the

MSPRC has the insurer or workers’ compensation entity name and address. Requesting such information specifically through an agent will delay receipt of the CPL.

13

Model Language for “Proof of Representation” or

“Consent to Release”

The MSPRC has separate downloadable

documents on www.msprc.info which provide model language for “proof of representation” and “consent to release” for purposes of interacting with the MSPRC.

Individuals/entities are not required to use this model language but must provide all of the information requested in the model language.

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