An official website of the United States government
The Representative Information page is step five in the New Claim process.
Representative information is required only if the injured party has a representative. If you choose to enter representative information, those fields marked with a red asterisk (*) are required. If there is no representative, set Type to "None."
| Field | Description |
|---|---|
| Type | Select the type of Representative from the drop-down list. Values include:
If the injured party does not have a representative, select None. If there is more than one representative for the Injured Party, enter the attorney’s information. Leave other fields blank if you select None for the Representative Type. |
| TIN | Enter the Federal Tax Identification Number of the representative. If the representative is part of a firm, supply the firm’s Employer Identification Number (EIN). Otherwise, supply the Representative’s Social Security Number (SSN). Field must contain 9 digits. |
| Representative | - |
| First Name | Enter the representative’s First Name using only alpha characters or embedded spaces. If the injured party has a representative, this field is required if Firm Name is not entered. |
| Last Name | Enter the representative’s Last Name. Use only alpha characters, embedded hyphens (dashes), embedded spaces, or apostrophes. |
| Firm Name | Enter the representative’s firm name if applicable. The field may contain alpha and/or numeric characters, spaces, commas, or these special characters, &, dash, apostrophe, period, @, #, forward slash, colon, or semi-colon. If provided, the field must contain at least 2 characters. |
| Address 1 | Enter the street number and street name of the representative. If no US address is available, leave this field blank and select “Foreign Country” from the State drop-down list. Required if the injured party has a representative. |
| Phone | Enter the representative’s phone number and extension (optional). Enter only numeric digits for the phone and extension. Leave the entire phone number blank for foreign representatives. If no U.S. phone number is available, leave this field blank and select "Foreign Country" from the State drop-down list. Phone number is required if the injured party has a representative. |
| Address 2 | Enter the second line of the representative’s mailing address, such as Attention To, apartment number, or suite number. |
| City | Enter the city name for the representative. |
| State | Select the state of the representative. If the representative does not have a U.S. mailing address, select “Foreign Country” for state and leave the other address fields and phone number blank. |
| Zip | Enter the five-digit U.S. postal code and ZIP+4 extension (optional). Leave blank if the Representative does not have a U.S. mailing address. |
| Continue | Click to submit information for verification and continue to the ORM and TPOC Information page if edits are passed. |
| Cancel | Click to open the Cancel New Claim? dialog. Click Cancel on the dialog to cancel the claim updates. Any information you entered will not be saved. |
| Save | Click to save the information that you have entered and continue working on this page. The save will trigger edits if the information you have entered contains format or consistency errors. |
| Save & Exit | Click to save your work to finish later. The application will save any information you have entered that does not have a data format error and return to the Claim Listing page. This information will be available for 30 calendar days before it will be deleted. |
September 2024
A federal government website managed and paid for by the U.S. Centers for Medicare and Medicaid Services.
7500 Security Boulevard, Baltimore, MD 21244