Beneficiary (Claimant/Plaintiff) Consent to Release for Obtaining Lien
BENEFICIARY (CLAIM ANT/PLAINTIFF) CONSENT TO RELEASE
FOR OBTAINING LIEN/CONDTIONAL PAY M ENTS WITH CMS/MEDICARE, (MSPRC)
The language below authorizes MSA Advocates, Inc., a Medicare Set Aside Vendor, to receive
information, including identifiable health information, from the Centers of Medicare & Medicaid Services
(CMS) relating to my liability insurance (including self-insurance), no-fault insurance or workers’
compensation claim. This authorization also provides authorization to MSA Advocates, Inc. to act on
my behalf to resolve any potential recovery claim that Medicare may have if there is a settlement,
judgment, award or other payment made on behalf of my insurance claims.
I , ______________________________(print your name exactly as shown on your Medicare card) hereby
authorize the CMS, its agents and/or contractors to release, upon request, information related to my
injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed
CHECK ON LY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE
INFORMATION AND REPRESE NT YOU WITH REGARD T O THE ABOVE:
(If you intend to have your information released to more than one individual or entity, you must complete
a separate release for each one.)
( ) Insurance Company ( ) Workers’ Compensation Carrier (X) Other: MSA Advocates, Inc.
Name of entity: MSA Advocates, Inc., a National Medicare Set Aside Vendor
Contact for above entity: Office Manager
Address: 505 E. Fayette Street, Suite 214, Syracuse, New York 13202
CHECK ON E OF THE FOLLOWIN G TO INDICATE HOW LONG CMS/MEDICARE MAY
RELEASE YOUR INFORMATI O N (The period you check will run from when you sign and date
( ) One Year ( ) Two Years or (X) Other: Until such time as the lien/conditional payment(s)
is/are resolved with the MSPRC on my behalf.
I understand that I may revoke this “consent to release information” at any time, in writing.
MEDICARE BENEFICIARY INFORMATION AND SI GNATURE:
Beneficiary Signature: _____________________________ Date signed: ________________
Note: If the beneficiary is incapacitated, the submitter of this document will need to include
documentation establishing the authority (power of attorney) for the individual signing on the
Medicare Health Insurance claim Number (The number on your Medicare card.): __________
Date of Injury or illness: __________________
Authorized Representative for MSA Advocates’ Signature/Date:______________ Dated: _______
Beneficiary (Claimant/Plaintiff) Consent to Release for Obtaining Lien PDF
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