Medicare Sign Up pack sample

INFORMATION FOR CLAIMANTS We will work directly with your appointed representative unless he or she asks us to work directly with you. Your representative may: • get information from your claim(s) file; • with your permission, designate associates who perform administrative duties (e.g. clerks), partners and/or parties under contractual arrangements (e.g., copying services) to receive information from us on his or her behalf (by checking the appropriate block and signing this form, you are providing your permission for your representative to designate such associates, partners, and/or contractual parties); • give us evidence or information to support your claim; • come with you, or for you, to any interview, conference, or hearing you have with us; • request a reconsideration, a hearing, or Appeals Council review; and • help you and your witnesses prepare for a hearing and question any witnesses. Also, your representative will receive a copy of the decision(s) we make on your claim(s). We will rely on your representative to tell you about the status of your claim(s), but you still may call or visit us for information. You and your representative(s) are responsible for giving Social Security accurate information. It is wrong to knowingly and willingly furnish false information. Doing so may result in criminal prosecution. We usually continue to work with your representative until (1) you notify us in writing that he or she no longer represents you; or (2) your representative tells us that he or she is withdrawing or indicates that his or her services have ended (for example, by filing a fee petition or not pursuing an appeal). We do not continue to work with someone who is suspended or disqualified from representing claimants. We will inform you if we suspend your representative. What Your Representative(s) May Charge Each representative you appoint can ask for a fee. To charge you a fee for services, your representative must get our authorization if you or another individual will pay the fee. However, as described in “Completing this form to appoint a representative, Part III Fee Arrangement” section of this form, under certain circumstances, we do not have to authorize the representative's fee. To request a fee, your representative must file a fee agreement or a fee petition. In either case, your representative cannot charge you more than the fee amount we authorize. If he or she does, promptly report this to your Social Security office. Filing A Fee Petition Your representative may file a fee petition when his or her work on your claim(s) is complete. This written request describes in detail the amount of time your representative spent on each service he or she provided you. The request also gives the amount of the fee the representative wants to charge for these services. Your representative must give you a copy of the fee petition and each attachment. If you disagree with the information shown in the fee petition, contact your Social Security office. Please do this within 20 days of receiving your copy of the petition. We will review the petition and consider the reasonable value of the services provided. Then we will tell you in writing the amount of the fee we authorize. Filing A Fee Agreement If you and your representative have a written fee agreement, one of you must give it to us before we decide your claim(s). We usually will approve the agreement if: • you both signed it; • the fee you agreed on is no more than 25 percent of past-due benefits, or $6,000 (or a higher amount we set and announced in the Federal Register), whichever is less; • we approve your claim(s); and • your claim results in past-due benefits. We will tell you in writing the amount of the fee your representative can charge based on the agreement. If we do not approve the fee agreement, we will tell you and your representative in writing. If your representative wishes to charge and collect a fee, he or she must file a fee petition. After we tell you the amount of the fee your representative can charge, you or your representative can ask us to look at it again if either or both of you disagree with the amount. If we approved a fee agreement, the person who decided your claim(s) also may ask us to lower the amount. Someone who did not decide the amount of the fee the first time will review and finally decide the amount of the fee How Much You Pay You never owe more than the fee we authorize, except for: • any fee a Federal court allows for your representative's services before it; and • out-of-pocket expenses your representative incurs or expects to incur, for example, the cost of getting your doctor's or hospital's records. Our authorization is not needed for such expenses. Your representative may accept money in advance as long as he or she holds it in a trust or escrow account. We usually withhold 25 percent of your past-due benefits to pay toward the fee for you if: • your retirement, survivors, disability insurance, and/or supplemental security income claim(s) results in past-due benefits; • your representative is an attorney or a non-attorney whom we have determined to be eligible to receive direct payment of fees; and • your representative registers with us for direct payment before we effectuate a favorable decision on your claim. You must pay your representative directly: • the rest of the fee you owe, if the amount of the authorized fee is more than the money we withheld and paid to your representative for you plus any amount your representative held for you in a trust or escrow account. • all of the fee you owe, if we did not withhold past-due benefits, (for example, because there are no past-due benefits; your representative waived direct payment, did not register for direct payment, you discharged the representative, or he or she withdrew from representing you, before we issued a favorable decision); or we withheld an amount from your past-due benefits, but your representative did not ask us to authorize a fee or tell us that he or she planned to ask for a fee within 60 days after the date of your notice of award and we released the withheld amount to you What Your Representative(s) May Do sample