Fillable Consent to Release Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

Fill Online, Printable, Fillable, Blank Consent to Release Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid) Form

Use Fill to complete blank online MEDICARE & MEDICAID pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Consent to Release Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

On average this form takes 5 minutes to complete

The Consent to Release Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid) form is 2 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

BROWSE MEDICARE & MEDICAID FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Consent to Release
Liability Insurance (Including Self-Insurance), No-Fault Insurance,
or Workers’ Compensation
Where to find Information on “Consent to Release” vs. “Proof of Representation”
Please refer to the PowerPoint document on this website titled: “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” for detailed information on
• When to use a “consent to release” document vs. a “proof of representation” document,
• Appropriate content for both documents,
• The need for appropriate documentation when there are two layers of representatives involved (examples:
attorney 1 refers a case to attorney 2; the beneficiary’s guardian hires an attorney to pursue a liability
insurance claim) or when a beneficiary’s representative signs a “consent to release” document on the
beneficiary’s behalf,
• What liability insurers (including self-insurers), no-fault insurers, and workers’ compensation entities must
have in order to obtain conditional payment information, and
• Use of agents by insurers’ or workers’ compensation.
General
A “consent to release” document is used by an individual or entity who does not represent the Medicare
beneficiary but is requesting information regarding the beneficiary’s conditional payment information. A
“consent to release” does not authorize the individual or entity to act on behalf of the beneficiary or make
decisions on behalf of the beneficiary.
Model Language
See attached. Use of the model language is not required, but any documentation submitted as a “Consent to
Release” must include the information the model language requests.
Where to Submit a “ Consent to Release” document:
Liability Insurance, No-Fault Insurance, Workers’ Compensation:
NGHP
PO Box 138832
Oklahoma City, OK 73113
Fax: (405) 869-3309
MODEL LANGUAGE
CONSENT TO RELEASE
The language below should be used when you, a Medicare beneficiary, want to authorize someone other than
your attorney or other representative to receive information, including identifiable health information, from the
Centers for Medicare & Medicaid Services (CMS) related to your liability insurance (including self-insurance),
no-fault insurance or workers’ compensation claim.
I, (print your name exactly as shown on your Medicare card)
hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my
injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed
below:
CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION
AND THEN PRINT THE REQUESTED INFORMATION:
(If you intend to have your information released to more than one individual or entity, you must complete a
separate release for each one.)
( ) Insurance Company ( ) Workers’ Compensation Carrier ( ) Other _______________________
(Explain)
Name of entity:
Contact for above entity:
Address:
Address Line 2:
City/State/ZIP:
Telephone:
CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR
INFORMATION
(The period you check will run from when you sign and date below.):
( ) One Year ( ) Two Years ( ) Other ________________________________
(Provide a specific period of time)
I understand that I may revoke this “consent to release information” at any time, in writing.
MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:
Beneficiary Signature: Date signed:
Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation
establishing the authority of the individual signing on the beneficiary’s behalf. Please visit
https://go.cms.gov/cobro for further instructions.
Medicare ID nu(The mber on your Medicare card.):
Date of Injury/Illness:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Consent to Release Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document