Letter of Representation

"*" indicates required fields

Type of Medicare Beneficiary Representative*
*Note -- If you have an attorney, your attorney may be able to use his/her retainer agreement instead of this language. (If the beneficiary is incapacitated, his/her guardian, conservator, power of attorney etc. will need to submit documentation other than this model language.) Please visit http://go.cms.gov/cobro for further instructions.
Representative's Name*
Beneficiary's Name*
Please print exactly as shown on your Medicare card
Number on your Medicare card
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Date of lllness/lnjury for which the beneficiary has filed a liability insurance, no-fault insurance or workers" compensation claim
MM slash DD slash YYYY
MM slash DD slash YYYY
How do you want the contract to be generated?*