Get Appendix I-3: Medicare Confidential Reporting Information Form

This guide provides clear and detailed instructions on how to fill out the Appendix I-3: Medicare Confidential Reporting Information Form online. Following these steps will help ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Medicare confidential reporting information form online.

1. Click the ‘Get Form’ button to obtain the Medicare Confidential Reporting Information Form and open it in your editing tool.
2. Begin by filling out the case name and case number in the designated fields at the top of the form. This information helps identify your specific case.
3. In Section A, indicate whether the injured party currently receives or has ever received Medicare Part A or B by selecting 'Yes' or 'No'. If the injured party is deceased, you will need to complete Section F as well.
4. Enter the injured party’s information, including their Medicare claim number (also known as HICN), last name, first name, middle name, and Social Security number.
5. Specify the injured party's gender and date of birth in Section B, ensuring the details match the information on their Social Security card.
6. In Sections C and D, provide details regarding the alleged incident, including the date of incident, state of venue, alleged cause of injury, and applicable ICD-9 diagnosis codes.
7. If there is an attorney or another representative for the injured party, fill out Section E with their information, including type, names, addresses, and contact details.
8. In the settlement information section, indicate the date and amount of the settlement, if applicable.
9. Complete the signature and attestation portion, ensuring that it is signed by the person completing the form or an authorized representative.
10. At the final step, review all entered information for accuracy, then save your changes. You can download, print, or share the completed form as necessary.

Take the necessary steps to complete your Medicare Confidential Reporting Information Form online today.