Medicare Consent to Release Form – Medical Records

Updated September 29, 2021

A Medicare consent to release medical records is a form used to authorize the release of information pertaining to a Medicare beneficiary’s medical condition and the payment/settlement associated with said condition. Whether it is an insurance company, workers’ compensation carrier, attorney, or other representative requesting this information, the beneficiary must complete consent forms for each requesting party. Medicare cannot divulge any of this information without the written consent of the beneficiary. If the beneficiary is incapacitated, an empowered individual can complete the form as long as proper documentation establishing the authority to sign on the beneficiary’s behalf is attached to the consent form.

How to Write

Step 1 – Download in Adobe PDF.

Step 2 – The beneficiary must print their name in the first blank space, as shown on their Medicare card.

Step 3 – Select the entity to which information will be sent. If multiple entities are to receive the beneficiary’s information, separate release forms must be completed for each requesting party. Next, enter the name, contact person, address, and telephone number of the entity.

Step 4 – To limit the period of time CMS is allowed to release the beneficiary’s information, select one of the checkboxes as shown below. If “Other” has been selected, enter a specific period of time in the space provided.

Step 5 – The beneficiary must sign and date the bottom section of the form as well as include their Medicare card number and the date the injury/illness occurred.