Medicare Questionnaire Template (Page 2 of 3) in pdf

Medicare Questionnaire Template Page 2

CMS

Medicare

Centers for Medicare & Medicaid Services

Noridian Administrative Services

Medicare Part B Release of Information Request

This is an Authorization for Release of Information form. Your signature on this form authorizes

Medicare to release information to the person, agency, company or organization that you name

below to Act On Your Behalf. The form will be on file for future Telephone, Written

Correspondence, of Appeal Requests. Please be aware, the form is not valid unless you sign and

date it. An * indicates that fields that you are required to complete. Please complete all * fields

before returning to our office.

Beneficiary Information (person with Medicare)

*Name:_______________________________________ *Medicare #:___________________

From your red, white & blue Medicare Card

*Date of Birth:_________________________*Telephone #:_____________________________

*Address:___________________________*City:_______________*ST:_______Zip:________

*Reason Why You are Filling Out This Request (please check one)

( ) At Request of he Beneficiary

( ) Other (specify reason)_________________________________________________________

*Type of Information to be released (please check one)

( ) Release ALL Information

( ) Specific Information to be released_______________________________________________

*Time Frame (please check one)

( ) On-going release

( ) Limited (give date range)_________________________to____________________________

Person, agency, company or organization to which you are authorizing Medicare to

disclose your personal medical information:

*Name:

Great Basin Physical Therapy and Performance Center, LLC

*Address:

1701 County Road, Suite B, Minden, NV 89423

*Phone & Fax:

Phone: (775) 782-4466

Fax: (775) 783-9708

Page 1 of 2

Medicare Questionnaire Template Page 2