Form no 0938 0950-2026

The document is a form from the Department of Health and Human Services, specifically for appointing a representative to act on behalf of a Medicare beneficiary in connection with claims or appeals under the Social Security Act. It includes sections for the beneficiary to appoint a representative, for the representative to accept the appointment, and options for waiving fees related to representation. Additionally, it outlines requirements for charging fees and conditions under which representatives must obtain approval for their fees, ensuring fair compensation while preventing conflicts of interest.

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Click ‘Get Form’ to open it in the editor.
In Section I, enter the name of the beneficiary and their Medicare number. This section authorizes your representative to act on your behalf regarding your claim.
Sign and date the form in Section I, providing your street address, phone number, city, state, and ZIP code.
In Section II, have your appointed representative fill in their name and professional status. They must sign and date this section as well.
If applicable, complete Section III by having the representative waive any fees for their services. They should sign and date this section.
Finally, if relevant, complete Section IV regarding waiving payment for items or services at issue. Ensure all signatures are included before submission.

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Versions	Form popularity	Fillable & printable
2024	4.4 Satisfied (56 Votes)
2018	4.8 Satisfied (81 Votes)
2015	4.4 Satisfied (160 Votes)
2012	4.3 Satisfied (70 Votes)
2011	4.2 Satisfied (53 Votes)
2010	4.7 Satisfied (65 Votes)
2005	4.4 Satisfied (64 Votes)