Medicare Questionnaire Template (Page 3 of 3) in pdf

Medicare Questionnaire Template Page 3

I authorize the use of a copy (including electronic copy) of this form and the disclosure of my

personal medical information described above. I understand refusal to authorize disclosure of

my personal medical information will have no effect on my treatment, enrollment, eligibility for

benefits, or the Medicare pay for the health service I receive.

______________________________________________________

__________________

*Signature of Beneficiary or Authorized Representative

*Date

If you are signing as an authorized representative, please describe the basis for your authority to

act for the beneficiary and attach appropriate documentation. (For example, Power of Attorney

or Appointment of Representative)

Please Note:

This Release of Authorization Request allows Medicare to disclose information from your

records to the requested person, agency, company or organization that you authorized.

Therefore, the information disclosed pursuant to the authorization may be redisclosed by the

recipient and may no longer be protected by law.

You also have a right to revoke this Release of Information Request by contacting our office in

writing, except to the extent that Medicare has already acted based on your permission. To

revoke your authorization, send a written request to the address below.

If you have any questions regarding this form please contact us at:

AK, AZ, HI, NV, OR, WA: 1-800-444-4606

ND:

1-800-247-2267

CO:

1-800-332-6681

SD:

1-800-437-4762

IA:

1-800-532-1285

WY:

1-800-442-2371

Return To:

Noridian Mutual Insurance Company

A CMS Contracted Carrier/Intermediary

4305 – 13

Avenue South

Fargo, ND 58103

Page 2 of 2

Medicare Questionnaire Template Page 3