Medicare Compensation Recovery Third party authority form (MO021)

Use this form to give us permission to release your compensation information and to give permission to a third party to sign relevant documentation on your behalf.

Download and complete the Medicare Compensation Recovery Third party authority form.

You can fill in this form and sign it digitally. You can do this by downloading it on a computer or a device that has Adobe Acrobat Reader. If you don’t have Adobe Acrobat Reader you can print it and sign it by hand.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 10 December 2021