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Medicare Consent Release Form Template

Easily Manage Patient Consents with Our Medicare Template

Navigating patient consent can be tricky, especially when transferring care between practices. This Medicare consent release form template helps healthcare organizations simplify the consent process by ensuring patients authorize their health information to be shared with other providers. You can streamline communication, enhance patient trust, and comply with regulatory requirements, all while maintaining HIPAA guidelines. Plus, our template features WCAG-aligned labels for accessibility. Explore the live template and see how it can work for you.

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Full legal name of Medicare beneficiary
Date of birth
Medicare Beneficiary Identifier (MBI)
Primary phone number
Email address
Are you authorizing Medicare to release information to another person or organization?
Yes
No
Name of person or organization authorized to receive your information
Recipient phone number
Recipient email address
Recipient relationship/type
Family member
Friend
Caregiver
Attorney or legal representative
Insurance agent/broker
Health care provider/clinic
Employer
Not applicable
Other
Please Specify:
If Other, describe the specific information to be released
Dates of service (From)
Dates of service (To)
Select the information you authorize to be released
Purpose of disclosure
Coordination or management of care
Insurance or benefits-related
Personal record keeping
Legal or financial matters
Research or education
Other or not specified
Prefer not to say
I consent to receive the authorized information by unsecured email if used, understanding the risk of re-disclosure in transit
Yes
No
Not applicable
I authorize Medicare and my health care providers to disclose the information indicated above to the recipient named on this form
Yes
No
I understand I may revoke this authorization at any time in writing, except to the extent action has already been taken in reliance on it
True
False
I understand the information disclosed may be re-disclosed by the recipient and may no longer be protected by HIPAA
True
False
Expiration date
Authorization expiration
On the expiration date below
One year from signature date
Two years from signature date
No expiration until revoked
Signer full legal name (type your name to sign)
Date of signature
Relationship of signer to beneficiary
Self (beneficiary)
Parent
Legal guardian
Power of attorney/Conservator
Spouse/Partner
Child
Other
Please Specify:
{"name":"Full legal name of Medicare beneficiary", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name of Medicare beneficiary, Date of birth, Medicare Beneficiary Identifier (MBI)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration related to Medicare Consent Release Form Template and FormCreatorAI

When to use this form

Use this Medicare consent to release form when you want Medicare or your health plan to share specific information with a trusted person or organization. Common cases include an adult child calling about bills, a licensed agent checking plan options, a hospital discharge planner coordinating services, or a pharmacy billing a vaccine. You decide who can receive details, what they can see, and for how long. This reduces delays, cuts callbacks, and speeds claims help. If you are onboarding a patient, pair this authorization with a Patient admission and consent form. For vaccine documentation or billing, you may also collect an Immunization record form.

Must Ask Medicare Consent Release Questions

  1. Who are you authorizing to receive your Medicare information?

    Full name, relationship, and organization help verify identity and avoid disclosure to the wrong person. Clear identification also lets you limit access to one caregiver, agent, or provider.

  2. What Medicare information may we share with this person?

    Choosing categories (eligibility, claims, billing, appeals, or all records) keeps disclosure to the minimum necessary. If the purpose is vaccine verification, limit it to proof of shots, such as the Flu shot proof form.

  3. Why are you sharing this information?

    Stating a purpose (care coordination, benefits counseling, or billing) guides staff on what to release and when. It also helps route requests to the right team and reduces follow-up questions.

  4. How long should this authorization remain in effect?

    An end date or event (for example, end of plan year) prevents unintended, open-ended access. You can also choose until revoked if you want ongoing support but keep the option to end it later.

  5. What is your Medicare number (MBI), and will you sign and date this authorization?

    Your MBI matches the request to your record and speeds processing. A signature and date confirm informed consent and your right to revoke in writing at any time.

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