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Release of Medicare Information Statement Print

This form is to be completed by a beneficiary appointing a party to act on his/her behalf when making telephone inquiries regarding their Medicare file on record with 1-800-Medicare. Send the completed form to:
 
Palmetto GBA
P. O. Box 100297
Columbia, SC 29202-3297

Click Here To Download MIRF Form In PDF Format

Click Here To Download MIRF Form In Microsoft Word Format

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