Medicare Portal Authorization - Cassandra Murray-Barja
AUTHORIZATION
I, , GIVE PERMISSION TO THE LAW OFFICE OF ROSENBAUM AND ASSOCIATES, TO SET UP A CLAIM AND OBTAIN MY MEDICARE INFORMATION FOR THIS CLAIM FROM THE MY MEDICARE PORTAL FOR THE DURATION OF THIS CLAIM FOR THE ACCIDENT OF . DATE:
My user name and password is as follows:USERNAME: __________________________________ PASSWORD: __________________________________
Leave this empty:
Your legal name
Click on "Agree & Sign" to legally sign this document and agree to the WP E-Signature Terms of Use. If you have questions about the contents of this document, you can email the document owner.
Document Name: Medicare Portal Authorization - Cassandra Murray-Barja
Click on "Agree & Sign" to legally sign this document and agree to the WP E-Signature Terms of Use.
Agree & Sign
