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Get Medicare Proof Of Representation Form

His model language also makes provisions for the information your representative must provide. Type of Medicare Beneficiary Representative (Check one below and then print the requested information): ( ) Individual other than an Attorney: Name: _____________________________ ( ) Attorney* Relationship to the Medicare Beneficiary: __________________ ( ) Guardian* Firm or Company Name: ________________________________ ( ) Conservator* Address: ( ) Power of Attorney* ______________.

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