Consent to Release Model Language. Consent to Release Model Language 2026

1. Click ‘Get Form’ to open the Consent to Release Model Language in the editor.
2. Begin by entering your name exactly as it appears on your Medicare card in the designated field.
3. Select who may receive your information by checking only one of the options: Insurance Company, Workers’ Compensation Carrier, or Other. If you choose 'Other', provide a brief explanation.
4. Fill in the requested information for the entity that will receive your information, including their name, contact person, address, city/state/ZIP, and telephone number.
5. Indicate how long CMS may release your information by checking one of the options: One Year, Two Years, or Other. If 'Other' is selected, specify a time period.
6. Sign and date the document in the designated fields. Ensure that if you are signing on behalf of an incapacitated beneficiary, you include necessary documentation.

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