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The form collects beneficiary identity details (HIC number, name, date of birth, gender, phone, and mailing address), specifies the authorized individual(s) and consent duration, and requires the beneficiary’s signature with a completion date. 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If no option is chosen, the consent remains valid for one year from the date shown on the form.",{"name":116,"@type":107,"acceptedAnswer":117},"Is the authorization form valid after the beneficiary’s death?",{"text":118,"@type":110},"No. The form is not valid after the beneficiary’s death, and the office must be contacted for the documentation required to authorize access after death.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283874,1791213041,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","| BENEFICIARY AUTHORIZATION FORM-RAILROAD MEDICARE   |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Please type or print all fields to process the Railroad Medicare Authorization Form.  \u003Cbr>Railroad Medicare cannot release information about the beneficiary without their permission.The  \u003Cbr>beneficiary must complete and return this authorization form to the address below before we can  \u003Cbr>discuss his or her Medicare benefits.   |  |  |  |  |  |  |\n| Beneficiary Information   |  |  | SEND COMPLETED FORM To:  \u003Cbr>PALMETTO GBA  \u003Cbr>Railroad Medicare Part B Office  \u003Cbr>P.O.Box 10066  \u003Cbr>Augusta,GA 30999-0001   |  |  |  |\n| 1   | HEALTH INSURANCE CLAIM NUMBER  \u003Cbr>PREFIX  \u003Cbr>6OR 9-DIGIT NUMBER   |  |  |  |  |  |\n| 2   | FIRST NAME   |  | Ml   |  | LAST NAME   |  |\n|  |  |  |  |  |  |  |\n| 3   | DATE OF BIRTH  \u003Cbr>/    /___   | □ Male  \u003Cbr>□ Female   |  |  |  | PHONE NUMBER  \u003Cbr>(    )   _-   |\n| 4   | MAILING ADDRESS   |  |  | CITY,STATE&ZIP CODE   |  |  |\n|  |  |  |  |  |  |  |\n| 5   | I give Railroad Medicare consent to give____  \u003Cbr>(Name)  \u003Cbr>_information regarding my Medicare claims and benefits.  \u003Cbr>my_  \u003Cbr>(Relationship)  \u003Cbr>How LONG WoULD YOU LIKE FOR THIS PERSON To BE ABLE To OBTAIN YOUR INFORMATION?  \u003Cbr>□ Until Further notice OR  \u003Cbr>__/    /   _To (end date)_   /    /____  \u003Cbr>口From (start date)  \u003Cbr>IMPORTANT!!If you do not choose one of the above,this consent will be valid for one year  \u003Cbr>from the date shown below.   |  |  |  |  |  |\n| 6   | MEDICARE BENEFICIARY's SIGNATURE   |  |  |  |  | DATE   |\n| For additional assistance,please contact Customer Service at 1-800-833-4455.We are available  \u003Cbr>Monday through Friday between the hours of 8:30 a.m.and 4:30 p.m.for all time zones with the  \u003Cbr>exception of PST,which receives service from 8 a.m.to 5 p.m.   |  |  |  |  |  |  |\n\n# How to fill out this Beneficiary Authorization Form\n\nPalmetto GBA Railroad Medicare has always been concerned with protecting the privacy of the manybcncficiarics that wc scrve,and one of the ways we do this is by making surc that your personal Medicarcinformation is given out to the right people.Please complete the attached authorization form and return itto our office.Once we have received the form,we will document on your records any individual you havegiven consent to and send you an acknowledgment letter.  \n# Follow these instructions carefully:\n\n## A.Completion of this form\n\nItcm 1:Enter the bencficiary's Health Insurancc Claim(HIC)number including thc alpha prcfixexactly how it is shown on the Medicare card.  \nItem 2:Enter the beneficiary's name exactly as it is shown on the Medicare card.  \nItem 3:Enter the beneficiary's date of birth,including month,day and year.Check the appropriate box for the beneficiary's gender.Enter beneficiary's telephone number(if available).  \nItem 4:Print the beneficiary's current mailing address,including city,state and zip.  \nItem 5:List the name of the person(s)you are giving consent to and their relationship to thebencficiary.  \nPlease check the box indicating how long the consent is valid for.If the consent is onlyvalid for a specific time period,please list the date that the consent should start and end.  \nItem 6:Please have the beneficiary sign the form and enter the date that the form wascompleted.  \n## B.Other authorization\n\nWe can also accept a copy of a Power of Attorney to list someone as authorized on the beneficiary'saccount.If you have a legal document that is signed and has a seal,if required by your state's laws,send acopy of the document to our office.  \n## C.Deceased beneficiary\n\nThe authorization form is not valid after the beneficiary's death.If you are looking to be authorized on abeneficiary's account after their death,please contact our office for details on what documentation isrcquired.You can contact us at 1-800-833-4455.","cbCainUA2KZaN9Gz","https://ap.wps.com/l/cbCainUA2KZaN9Gz","pdf",53347,"English","# How to fill out this Beneficiary Authorization Form\n## A. Completion of this form\n## B. Other authorization\n## C. Deceased beneficiary","[{\"question\":\"What information must the beneficiary provide in the authorization form?\",\"answer\":\"The beneficiary must provide the HIC claim number, name, date of birth and gender, telephone (if available), and mailing address, plus the authorized person’s name and relationship.\"},{\"question\":\"How does the beneficiary choose how long the consent is valid?\",\"answer\":\"The beneficiary selects a consent duration using the provided options. If no option is chosen, the consent remains valid for one year from the date shown on the form.\"},{\"question\":\"Is the authorization form valid after the beneficiary’s death?\",\"answer\":\"No. The form is not valid after the beneficiary’s death, and the office must be contacted for the documentation required to authorize access after death.\"}]","Railroad Medicare Beneficiary Authorization Form - How to Fill Out | PDF",1789621212]