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PROOF OF REPRESENTATION FOR

The language below should be used when you, the Medicare beneficiary, want lo inform the Centers for Medicare & Medicaid Services (CMS) that you have given another individual the authority to represent you and act on your behalf with respect to your claim for liability insurance, no-fault insurance, or workers' compensation, including releasing identifiable health information or resolving any potential recovery claim that Medicare may have if there is a settlement, Judgment, award, or other payment. You are not required to use this model language, but proof of representation must include the information provided in this model language. Your representative must also sign that he/she has agreed to represent you. This model language also makes provisions for the information your representative must provide.

Type of Medicare Beneficiary Representative:

Name of Representative
Relationship to Beneficiary
Firm or Company Name
Address of Representative
Telephone of 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.

Medicare Beneficiary Information and Signature/Date:

Beneficiary's name (please print exactly as shown on your Medicare card):

Beneficiary's Health Insurance Claim Number (number on your Medicare card):

Date of lllness/lnjury for which the beneficiary has filed a liability insurance, no-fault insurance or workers" compensation claim:

Beneficiary's Signature:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 2, 2022 12:35 pm CDT

Proof of Representation Uploaded by Pedro "Pete" Perez Navejar - booking@pureconceptions.com IP 108.70.53.227