2018
MODEL LANGUAGE FOR FIXED PERCENTAGE OPTION
ALL INFORMATION IS REQUIRED
Fixed Percentage Option
P.O. Box 138880
Oklahoma City, OK 73113
Dear Benefits Coordination & Recovery Center (BCRC):
I received a liability insurance settlement for $ __________________ and I choose the fixed payment option to repay
Medicare. My payment will be $ ________________
_____, which is 25% of my total settlement amount.
(Note: Do not reduce the total settlement amount for attorney fees and costs.)
Beneficiary Name: _______________________________ Da
te of Incident: _____________________
Medicar
e Number: _______________________________ Date of
Settlement: ___________________
Brief Description of Injury:
_______________
________________________________________________________________________
_______________________________________________________________________________________
I certify that the following statements are true:
• I have received a liability insurance settlement for $5,000 or less.
• I have not received any other bill or request for payment from Medicare related to this liability insurance
settlement.
• I agree to pay $ ____________________, which is 25% of my total settlement.
• I understand that, as part of choosing the option, I have given up my right to appeal the fixed payment amount or
request a waiver of recovery.
• The injury that I alleged was a physical trauma-based injury. (This means that it did not relate to ingestion,
exposure, or a medical implant.)
• I have not gotten and do not expect to get any other settlements, judgments, awards, or other payments related to
the incident referenced above. (However, if I receive any, I will notify Medicare because Medicare may have an
additional recovery claim.)
Check One:
I have included a check or money order for $ _______________ made out to Medicare. This amount is 25% of
my total settlement. I have included my name and Medicare number on the check or money order.
I have NOT included payment and will pay once I receive the bill.
Sincerely,
Name: ________________________________________ Date: ______________________________
P
lease check if you are an att
or
ney or representative signing for a beneficiary. In order to sign for the beneficiary,
you MUST submit with this form (or have previously submitted) a valid proof of representation (model language
is available on the CMS.gov website at Medicare’s Recovery Process
).
click to sign
signature
click to edit
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