PROOF OF REPRESENTATION FOR THE CENTER FOR MEDICARE & MEDICAID SERVICES
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):
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’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:
PO Box 138832
Oklahoma City, OK 73113
Fax: (405) 869-3309