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.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

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: 1 May 2023.
QC 19951