How to Write
Step 1 – Download in 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.
