Fillable Printable Beneficiary (Claimant/Plaintiff) Consent to Release for Obtaining Lien

Beneficiary (Claimant/Plaintiff) Consent to Release for Obtaining Lien

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BENEFICIARY (CLAIM ANT/PLAINTIFF) CONSENT TO RELEASE

FOR OBTAINING LIEN/CONDTIONAL PAY M ENTS WITH CMS/MEDICARE, (MSPRC)

The language below authorizes MSA Advocates, Inc., a Medicare Set Aside Vendor, to receive

information, including identifiable health information, from the Centers of Medicare & Medicaid Services

(CMS) relating to my liability insurance (including self-insurance), no-fault insurance or workers’

compensation claim. This authorization also provides authorization to MSA Advocates, Inc. to act on

my behalf to resolve any potential recovery claim that Medicare may have if there is a settlement,

judgment, award or other payment made on behalf of my insurance claims.

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 ON LY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE

INFORMATION AND REPRESE NT YOU WITH REGARD T O THE ABOVE:

(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 (X) Other: MSA Advocates, Inc.

Name of entity: MSA Advocates, Inc., a National Medicare Set Aside Vendor

Contact for above entity: Office Manager

Address: 505 E. Fayette Street, Suite 214, Syracuse, New York 13202

Telephone: 315-472-7965

CHECK ON E OF THE FOLLOWIN G TO INDICATE HOW LONG CMS/MEDICARE MAY

RELEASE YOUR INFORMATI O N (The period you check will run from when you sign and date

below.):

( ) One Year ( ) Two Years or (X) Other: Until such time as the lien/conditional payment(s)

is/are resolved with the MSPRC on my behalf.

I understand that I may revoke this “consent to release information” at any time, in writing.

MEDICARE BENEFICIARY INFORMATION AND SI GNATURE:

Beneficiary Signature: _____________________________ Date signed: ________________

Note: If the beneficiary is incapacitated, the submitter of this document will need to include

documentation establishing the authority (power of attorney) for the individual signing on the

beneficiary’s behalf.

Medicare Health Insurance claim Number (The number on your Medicare card.): __________

Date of Injury or illness: __________________

Authorized Representative for MSA Advocates’ Signature/Date:______________ Dated: _______