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Authorization for Use and Disclosure of Private/Protected Health Information Instruction Sheet TOP OF FORM: OHA STAFF MEMBER SELECTION 1. In the center box, click the drop down box to select the staff.

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OHA Authorization for Release of Information with...
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Where to Send This Form. Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision.

An Appointment of Representative is valid for one year, unless revoked, from the date that the appointment is signed by both the member and the representative.

By regular mail. You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number __, Room C4–26–05, 7500 Security Boulevard, Baltimore, Maryland 21244–1850.

An Authorized Representative is a person chosen by a Medicare beneficiary to help with Medicare-related matters, such as the following: Researching and choosing Medicare coverage. Handling Medicare claims and payments. Appealing Medicare coverage decisions.

Form CMS-1696 Approved. CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB No. 0938-0950. APPOINTMENT OF REPRESENTATIVE.

Appointment of Authorized Representative (Purpose: To grant permission for another individual or company to act on your behalf in filing a Grievance or Appeal).

How do I authorize a Medicare personal representative? Fill out Medicare's Authorization to Disclose Personal Health Information form to let the agency know whom you've chosen to access your Medicare personal health information. The form doesn't authorize that person to make medical decisions for you.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232