P ROOF OF REPRESENTATION Authorized Representative 2025

1. Click ‘Get Form’ to open the P ROOF OF REPRESENTATION Authorized Representative in the editor.
2. Begin by entering the Medicare beneficiary's name exactly as it appears on their Medicare card in the designated field.
3. Next, input the beneficiary’s Health Insurance Claim Number, which can also be found on their Medicare card.
4. Fill in the date of illness or injury for which the beneficiary is filing a claim. Ensure this date is accurate to avoid any processing issues.
5. In the section for authorized representative details, select the appropriate type of representative (e.g., Attorney, Guardian) and provide their name and law firm information.
6. Both the beneficiary and representative must sign and date where indicated. Use our platform’s signature feature for convenience.

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