Medicare Consent to Release Form – Medical RecordsMedicare Consent to Release Form – Medical Records
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“Consent to Release”
Liability Insurance (Including Self-Insurance), No-Fault Insurance,
or Workers’ Compensation

Where to find Information on “Consent to Release” vs. “Proof of Representation”
Please refer to the PowerPoint document on this website titled: “Rules and Model Language for ‘Proof of
Representation’ vs. ‘Consent to Release’ for Medicare Secondary Payer Liability Insurance (Including SelfInsurance), No-Fault Insurance, or Workers’ Compensation” for detailed information on

When to use a “consent to release” document vs. a “proof of representation” document,
Appropriate content for both documents,
The need for appropriate documentation when there are two layers of representatives involved (examples:
attorney 1 refers a case to attorney 2; the beneficiary’s guardian hires an attorney to pursue a liability
insurance claim) or when a beneficiary’s representative signs a “consent to release” document on the
beneficiary’s behalf,
What liability insurers (including sel