Please read the following guidelines for completing the Written Authorization form.

The purpose of the Written Authorization form is for the beneficiary or patient to allow written consent to another party (e.g., spouse, adult, child, provider, insurance company) that is requesting claim information about the beneficiary or patient. The information may not be released to the outside party until written consent is provided by the patient. The Written Authorization form is the correct form to fill out to provide written consent of information.

The following people are authorized to sign the written authorization form:

• The patient (not the spouse);
• Power of attorney if the patient is unable to sign (document must be provided);
• Parent (if the patient is under the age of 18);
• Legal guardian (proof of guardianship document must be provided); or
• Representative of the estate for deceased (copy of the death certificate and a copy of the representative of estate documents must be provided).

To complete the form please:

• Enter the name and address of the requestor in Item #1
• Check the time limit for the release of information.
• Complete the occurrence on the form under Item #3
• Sign your name, give the Medicare HIC Number that the release applies to, address and current date.

If you have any questions about completing this form, please call Medicare Services customer service department at 1-800-MEDICARE (1-800-633-4227).