PROOF OF REPRESENTATION FOR THE CENTER FOR MEDICARE & MEDICAID SERVICES

By Ben Sessions on October 12th, 2016 in Uncategorized

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