Release Forms

• Allsup Authorization For Release of Information – Allsup’s form that allows Allsup to release claim status to a third party.
• Form SSA-3288 – Social Security Administration (SSA) form that allows Allsup to gather Medicare entitlement information and Social Security Disability Insurance (SSDI) filing information. Please note, although a possible charge is indicated, there will be NO charge for obtaining the requested information from the SSA.
• CMS Consent to Release – HIPAA form that is submitted if The Centers for Medicare & Medicaid Services (CMS) needs to be contacted in regards to the workers’ compensation claim.
• CMS Consent to Release - Conditional Payments

Medicare Conditional Payment Release Forms:

• Allsup Authorization For Release of Information – Allsup’s form that allows Allsup to release claim status obtained from MSPRC back to the client.
• Consent to Release – Client* – Letter that is signed by the claimant which allows the client to obtain and discuss Medicare conditional payment information with the Medicare Secondary Payer Recovery Contractor (MSPRC).
• Medicare Conditional Payment Investigation Letter* – Letter that is printed onto client letterhead and signed by the client which allows Allsup to obtain and discuss Medicare conditional payment information with the Medicare Secondary Payer Recovery Contractor (MSPRC) pertaining to the claimant.