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Consent To Release

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 rhe 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:

WHO MAY RECEIVE 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.)

Name of Entity
Contact For Above Entity
Address
Telephone

HOW LONG CMS MAY RELEASE YOUR INFORMATION

(The period will run from when you sign and date below.):

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

MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:

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 http://go.cms.gov/cobro for further instructions.

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

Date of lnjury/lllness:

Beneficiary Signature:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 3, 2022 9:58 am CDT

Consent To Release Uploaded by Pedro "Pete" Perez Navejar - booking@pureconceptions.com IP 49.36.230.60