Consent to Release

CMS Case Control Number: 
The Privacy Act of 1974 (Public Law 93-579) prohibits the government from revealing information from personal files without express written permission from the person involved. Disclosure of personal records to an attorney or other representative who is acting on behalf of another person is prohibited, unless the individual to whom the record pertains has consented. 
I,                   , hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and its contractors to disclose, discuss, and release orally or in writing, information related to my injury and settlement to the individual(s) and firm(s) listed below. The consent is for my current workers’ compensation or liability claim and is on an ongoing basis. An additional consent to release will not be necessary unless and until I revoke this consent in writing. Additionally, the need for a Workers’ Compensation Medicare Set-Aside Arrangement and the process has been explained to me, and I approve of the contents of my submission.
							Beneficiary Initials ______
Please Check
 Claimant’s Attorney					_______________________________
							(name and/or firm)

 Employer’s Attorney					_______________________________
							(name and/or firm)

 Workers’ compensation carrier			_______________________________
							(name and/or firm)

 Other 						Genex Services, LLC_______________
							(name and/or firm)

____________________________________		____________________
Claimant’s Signature					Date Signed

_____________________				________________________________
Date of Injury						Social Security or Medicare Number
							(Health Insurance Claim #/HICN or Medicare ID)