Proof 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. Individual other than an Attorney Attorney Guardian Conservator Power of Attorney Representative's Name* First Last Representative's Email* Relationship to the Medicare Beneficiary* Firm or Company Name* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone*Beneficiary's Name*Please print exactly as shown on your Medicare card First Beneficiary's Email* Beneficiary's Health Insurance Claim Number*Number on your Medicare card HiddenBeneficiary's Signature Reset signature Signature locked. Reset to sign again Date of Illness/Injury*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 HiddenDate MM slash DD slash YYYY How do you want the contract to be generated?* Send the contract to the beneficiary via email Generate the contract to be signed right now
