Medicare Consent to Release Form

Medicare Consent to Release Form

The medicare consent to release form is a form that allows a beneficiary to provide all of the information needed for the Centers for Medicaid and Medicare Service (also known as CMS), to release information regarding an injury/illness and/or a settlement for the date (specified) of illness or injury.

This information may be released to a Worker’s Compensation Carrier, Insurance company, Attorney’s or to whomever the beneficiary would like the information to be sent for the purpose of any form of advocacy. If information will be requested for more than one entity, the beneficiary, must complete a separate release form for each one.

Should it be the case that  the beneficiary is incapacitated, the person submitting the document must include additional documentation that would establish the authority of the individual signing on behalf of the beneficuary. These specific instructions may be located online by visiting

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – Begin by carefully reviewing page one of the document –

  • Proceed to the form on page two (2)

Step 3 – Consent to Release – Read the first two paragraphs before entering any information:

  • The beneficiary must be printed into the first line of the form, exactly as it’s shown on their Medicare Card
  • Check the box next to only one entity, (per release form) indicating to whom the information shall be received
  • Enter the name of the entity
  • Submit the contact name for the stated entity
  • Complete address
  • Telephone number

Step 4 – Period for Release –

  • The beneficiary must specify a time frame in which the CMS may, with permission, release beneficiary information
  • If checking “Other” enter, into the line provided, a specific time frame

Step 5 – Medicare Beneficiary Information and Signature – Submit the following:

  • Beneficiary’s Signature
  • Date of signature in mm/dd/yyyy format
  • The Beneficiary’s Medicare Number as stated on the card
  • Date of illness or injury