Get Cms Proof Of Representation Form Or Executed Client Retainer ...

Filling out the CMS Proof Of Representation Form is an important step in ensuring that your legal representative can act on your behalf regarding Medicare claims. This guide will walk you through the process of completing the form online with clarity and ease.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the CMS Proof Of Representation Form. This will open the document in your online editor.
2. Select the type of representative you are. In the designated box, mark 'Attorney' if applicable, or choose any other relevant option by placing an 'X' in the corresponding checkbox.
3. Provide the name of the attorney or law firm representing you. Fill in the law firm's name on the line provided.
4. Enter the address of the law firm, including street address, city, state, and zip code. Ensure accuracy in this information as it is crucial for legal communication.
5. Input the phone number of the law firm. This will be used for further correspondence between you, the law firm, and Medicare.
6. Proceed to the section for Medicare beneficiary information. Print the beneficiary’s name exactly as it appears on the Medicare card.
7. Fill in the beneficiary’s Health Insurance Claim Number, which is the number found on their Medicare card.
8. Document the date of illness or injury relevant to the claim for liability insurance, no-fault insurance, or workers’ compensation.
9. Have the beneficiary sign the form in the designated signature area, and add the date they signed.
10. The representative, in this case, the attorney, must also sign the form and include the date of their signature.
11. Once all information is accurately filled in, you can save the changes, download the document, print it for your records, or share it as needed.

Complete your CMS Proof Of Representation Form online today to ensure proper representation.