Sample authorization form

 

Sample authorization form

SAMPLE WORDING FOR AUTHORIZATIONS

ONE-TIME AUTHORIZATION

For Use by Provider

Beneficiary Name____________________________HIC#___________________________
I request that payment of authorized Medicare benefits be made to me or on my behalf to (Provider Name) for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
___________________________________________Date_________________
(Beneficiary signature)





For Use by a Facility

Beneficiary Name_______________________________________HIC#________________
I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in (Name of Facility), including provider services. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or benefits for related services.
____________________________________________Date________________
(Beneficiary signature)



                                                    MEDIGAP AUTHORIZATION



Beneficiary Name________________________________________HIC#_______________
Medigap Policy Number_______________________________________
I request that payment of authorized Medigap benefits be made to either me or on my behalf to (Provider Name), for any services furnished to me by this provider. I authorize any holder of medical information to release to (Name of Medigap Insurer) any information needed to determine these benefits or the benefits payable for related services.
_____________________________________________Date_______________
(Beneficiary signature)

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