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PROOF OF REPRESENTATION FOR THE CENTER FOR MEDICARE & MEDICAID SERVICES

Posted by Ben Sessions | Oct 12, 2016 | 0 Comments

In every personal injury case in which

PROOF OF REPRESENTATION

The undersigned Medicare beneficiary here states that he/she is represented by The Sessions Law Firm, LLC, a Georgia limited liability company and law firm. The undersigned authorizes the Center for Medicare & Medicaid Services to communicate with The Sessions Law Firm, LLC, regarding the undersigned beneficiary treatment and benefits payments.

Type of Medicare Beneficiary Representative: Attorney

Medicare Beneficiary Information and Signature/Date:

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

Date:

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

Date of Illness/Injury for which the beneficiary has filed a liability insurance, no-fault insurance or workers' compensation claim:

Beneficiary Signature: Date:

Representative Signature/Date:

Representative's Signature: Date:

NOW THAT YOU HAVE THE PROOF OF REPRESENTATION FROM YOUR CLIENT, WHERE DO YOU SEND IT?

Liability Insurance, No-Fault Insurance, Workers' Compensation:
NGHP
PO Box 138832
Oklahoma City, OK 73113
Fax: (405) 869-3309

About the Author

Ben Sessions

I work to provide exceptional service, attention, and results to each of my clients. Most of clients come to me because they are in a completely overwhelming situation. They need someone that will do more than address their legal problems.

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