Medicare

Authorization to release information to
Centers for Medicare and Medicaid Services

 

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Smart Nutrition by Karen Graham, RD for any services furnished to me by that provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

 

Patient Name
Medicare Number