Medicare release consent form

 Using a Medicare consent to release medical records form, a beneficiary's medical history, settlement, and payments associated with the condition can be released. It does not matter from whom the beneficiary receives this information; it may be an insurance company, an attorney, or another representative. A Medicare beneficiary's written consent is required for the disclosure of any of this information. A power of attorney can be used to fill out the consent form if the beneficiary is incapacitated, provided that the consent form is accompanied by appropriate documentation.  

Medicare release consent form template

Medicare release consent form

Individuals or entities requesting information regarding a Medicare beneficiary's conditional payment use "consent to release" documents. An individual or entity who consents to release does not have the authority to act on behalf of the beneficiary or to make decisions on their behalf.    

A guide to filling a Medicare consent to release medical record form

If you are a Medicare beneficiary and you want someone other than your attorney to receive information, including identifiable health information, from the Centers for Medicare & Medicaid Services (CMS), please utilize the following language and pattern.

Stage 1 - Download the document in PDF format or use our document generator to create a custom copy. 

Stage 2 - The beneficiary should print their name in the first blank space, as it appears on their Medicare card. Below is what can be found under this section on the consent form;

  • Name of entity: This will contain their complete legal name

  • Contact for the above entity: Please include a valid and current contact address by which they can be easily contacted. 

  • Telephone: A valid phone number is required for each entity(s)

Stage 3 - Select the entity that will receive the information. Whenever the beneficiary's information is to be released to multiple parties, separate forms must be filled out for each party. You then need to enter the name, contact details, address, and phone number of the organization.  

Stage 4 - As shown below, you can limit the amount of time CMS is allowed to release information about the beneficiary by selecting one of the checkboxes. If "Other" has been selected, enter a specific period in the space provided. The options available could range from one(1) year, two (2) years, and even beyond. Note that these are health-related and sensitive information hence the need for regulation.

Step 5 - The beneficiary must sign and date the bottom section of the form and include their Medicare card number as well as the date of the incident. The medicare number must be written accurately to ensure there is no misrepresentation or misinformation.

Download our free Medicare release consent form in an instant to create a legally binding document.

Download our free Medicare release consent form in an instant to create a legally binding document.

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