The Railroad Medicare Beneficiary Authorization Form is available in Acrobat's Portable Document Format (PDF). In order to view and print PDF documents, you must first download and install the Acrobat Reader program.
To access or download the Beneficiary Authorization Form, click on the link at the bottom of the page.
In this age of technology, privacy is more important than ever. Palmetto GBA Railroad Medicare has always been concerned with protecting the privacy of the many beneficiaries that we serve, and one of the ways we do this is by making sure that your personal Medicare information is given out to the right people.
If you call our customer service office to ask questions about your Part B Medicare, before we can answer your questions, you will always be asked to give your:
- Full Name
- Date of Birth
- Health Insurance Claim Number
- Telephone Number
If your spouse or anyone else calls for you, we will not be able to give any details about your Medicare unless we have your permission. While we understand that sometimes it may seem inconvenient, The Privacy Act of 1974 says that Medicare cannot release any specific information about your benefits to someone else unless you give your verbal or written permission.
Verbal permission has to be given over the phone at the time of each call. Since written permission is more detailed and is used for future reference, it must include the following:
If we do not have your verbal or written consent, the only information we can release is:
- The name of the person or group to whom information can be given
- The specific types of information (data or records) that can be released
- Your signature and date you signed your name
- Length of authorization (ongoing or one-time only)
If you know that your spouse or someone else will be calling for you on a regular basis, you might consider sending in written permission for them. Click on the link below for a form you can fill out and return to us so that your records can be updated and your privacy will remain protected.
- Claim has/has not been received
- Claim has/has not been processed
- A Medicare Summary Notice (MSN) can be expected by a certain date