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.
| Question | Answer |
|---|---|
| Form Name | Proof Of Representation |
| Form Length | 15 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min 45 sec |
| Other names | medicare proof of rep form, medicare letter of representation, cms proof of representation form, medicare proof of representation |
“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
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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
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
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“Consent to Release” vs. “Proof of Representation” –
What’s the Difference?
•Proof of Representation
filing an appeal (if appropriate) when that beneficiary is involved in a liability, workers’ compensation, or
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.
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“Consent to Release” vs. “Proof of Representation” –
What’s the Difference?
•Consent to Release – The 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.
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Proof of Representation –
What is required?
The following pages will address:
•Beneficiary
•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
•Agents for insurers or workers’ compensation carriers.
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Proof of Representation –
What is required? (continued)
Beneficiary
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.
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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
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Proof of Representation –
What is required? (continued)
Beneficiary guardians, conservators, power of attorney, Medicare representative payees.
•Guardian or Conservator
•Power of Attorney
•Representative Payee
representative payee for the Medicare beneficiary, and the MSPRC will verify this status within CMS’ systems.
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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
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 attorney – The 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. |
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