Proof of Representation
Medicare Beneficiary Information:
Beneficiary’s Name (As shown on your Medicare/Medicaid card): ____________________________________________
Beneficiary's Health Insurance Claim No. (As shown on your Medicare card): __________________________________
Date of Illness/Injury: ____________________________________
I, ____________________________________ hereby authorize the Centers for Medicare and Medicaid Services (CMS), its
(PRINT)
agents and/or contractors to release any and all information regarding status of conditional payments related to the
injury/illness and/or settlement that have/have not been made on the above specified claim. I am entrusting PROVIDIO
LIEN COUNSEL, 208 N. EASTON ROAD, WILLOW GROVE, PA 19090 to submit and receive information on my behalf in
order to resolve Medicare's right to recovery.
Signature or Beneficiary or Personal Representative
Date
Relationship of Representative
If you are signing on behalf of the patient, please explain your relationship and attach court approved documentation.
Attorney Signature
Date
Providio accepts this beneficiaries request for our representation in the resolution of conditional payments that may
have been made as a result of this loss.
Authorized Providio Lien Counsel Signature
Date
(an electronic signature may be used)
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