Fillable Proof of Representation Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

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Proof of Representation Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

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The Proof of Representation Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid) form is 2 pages long and contains:

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  • 5 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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Proof of Representation
Liability Insurance (Including Self-Insurance), No-Fault Insurance,
or Workers’ Compensation
Where to Find Information on “Proof of Representation” vs. “Consent to Release”
Please refer to the PowerPoint document on this website titled: “Rules and Model Language for ‘Proof of Representation’
vs. ‘Consent to Release’ for Medicare Secondary Payer Liability Insurance (Including Self- Insurance), No-Fault
Insurance, or Workers’ Compensation” for detailed information on:
• When to use a “proof of representation” document vs. a “consent to release” document,
• Appropriate content for both documents,
• Use of attorney retainer agreements as proof of representation if certain criteria are met,
• The need for appropriate documentation when there are two layers of representatives involved (examples:
attorney 1 refers a case to attorney 2; the beneficiary’s guardian hires an attorney to pursue a liability insuranc
e
c
laim) or when a beneficiary’s representative signs a “consent to release” document on the beneficiary’s behalf,
• What liability insurers (including self-insurers), no-fault insurers, and workers’ compensation entities must have
in order to obtain conditional payment information, and
• Use of agents by insurers’ or Workers’ Compensation.
General
Proof of representation is required in order for the Benefits Coordination & Recovery Center (BCRC) to communicate
with and provide information to a Medicare beneficiary’s representative. Once the BCRC has the appropriate
documentation, it can communicate with the representative and act upon requests made by the representative on behalf of
the beneficiary. This includes furnishing conditional payment information and/or a recovery demand letter as well as
addressing questions regarding the specific claims included in the conditional payment information, appeal requests or
waiver of recovery requests.
Model Language
See attached. Use of the model language is not required, but any documentation submitted as a “Proof of Representation”
document must include the information the model language requests.
Where to Submit Proof of Representation:
Liability Insurance, No-Fault Insurance, Workers’ Compensation:
NGHP
P.O. Box 138832
Oklahoma City, OK 73113
Fax: (405) 869-3309
MODEL LANGUAGE
Proof of Representation
The language below should be used when you, the Medicare beneficiary, want to inform the Centers for Medicare &
Medicaid Services (CMS) that you have given another individual the authority to represent you and act on your behalf
with respect to your claim for liability insurance, no-fault insurance, or workers’ compensation, including releasing
identifiable health information or resolving any potential recovery claim that Medicare may have if there is a settlement,
judgment, award, or other payment. You are not required to use this model language, but proof of representation must
include the information provided in this model language. Your representative must also sign that he/she has agreed to
represent you. This model language also makes provisions for the information your representative must provide.
Note: If you have an attorney, your attorney may be able to use his/her retainer agreement instead of this language. (If the
beneficiary is incapacitated, his/her guardian, conservator, power of attorney etc. will need to submit documentation other
than this model language.) Please visit https://go.cms.gov/cobro
for further instructions.
Type of Medicare Beneficiary Representative (Check one below and then print the requested information):
Individual other than an Attorney:
___________________________________
Attorney
Guardian
Conservator
Power of Attorney
Name: _____________________________________________
Relationship to the Beneficiary: _________________________
Firm or Company Name: ______________________________
Address: ___________________________________________
Addres
s Line 2:______________________________________
City/State/ZIP: ______________________________________
Telephone:__________________________________________
Medicare Beneficiary Information and Signature/Date:
Beneficiary’s Name:_________________________________________________________________________________
as shown on your Medicare card) (please print exactly
Beneficiary’s Medicare ID (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’s Signature: _______________________________________________ Date signed: ____________________
Representative Signature/Date:
Representative’s Signature: ___________________________________________ Date signed: ____________________
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Proof of Representation Liability Insurance (Including Self-Insurance), No-Fault (Medicare & Medicaid)

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Completed 13 April 2021

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