Proof Of Representation Template
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1PROOF OF REPRESENTATION
Type of Medicare Beneficiary Representative (Check one below and then print the requested
information):
( X ) Individual other than an Attorney:
Name: Blackburn Group Inc. and its representatives
including but not limited to Scott LeCompte
( ) Attorney*
Relationship to the Medicare Beneficiary: Medicare Vendor
( ) Guardian*
Firm or Company Name: Blackburn Group Inc.
( ) Conservator*
Address: 6709 Glenkirk Rd. Baltimore, MD. 21239-1411
( ) Power of Attorney*
Telephone: 443-841-5255
Medicare Beneficiary Information and Signature/Date:
Beneficiary’s Name (please print exactly as shown on your Medicare card): ________________________
Beneficiary’s Health Insurance Claim Number (number on your Medicare card): ____________________
Date of Illness/Injury for which the beneficiary has filed a liability insurance, no-fault insurance or
workers’ compensation claim: _______________________
Beneficiary Signature: ____________________________________Date signed: ___________________
Representative Signature/Date:
Representative’s Signature: ________________________________Date signed: ___________________
Blackburn Group, Inc., 6709 Glenkirk Road, Baltimore, MD. 21239-1411, Phone# 443-841-5255
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Parent category: Medical