Medicare Authorization to Disclose Personal Health Information

Forms and Documents

Document Name	Status
Form CMS-10106 Medicare Authorization to Disclose Personal Health Information Form and Instruction	Modified
CMS-10106.Responses to Public Comments from 30-d FRN.doc Supplementary Document	2007-11-20
CMS-10106 REVISED Supporting Statement-2-19-08 (3).doc Supporting Statement A	2008-03-21

IC Document Collections

IC ID	Document Title	Status
8778	Medicare Authorization to Disclose Personal Health Information Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0930	ICR Reference No: 200711-0938-015
Status: Historical Active	Previous ICR Reference No: 200409-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Authorization to Disclose Personal Health Information
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/25/2008
	Date Received in OIRA: 11/21/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2011	36 Months From Approved	03/31/2008
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	250,000	0	250,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Unless permitted or required by law, the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule prohibit covered entities from disclosing an individual's protected health information to a third party without a valid privacy authorization. The authorization must include specified core elements and certain statements. Medicare beneficiaries will use the "Medicare Authorization to Disclose Personal Health Information" to authorize Medicare to diclose their protected health information to a third party.

---

Authorizing Statute(s): PL: Pub.L. 104 - 191 164.508 Name of Law: Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 31839	06/08/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 48646	08/24/2007
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Authorization to Disclose Personal Health Information	CMS-10106, CMS-10106	Medicare Authorization to Disclose PHI Form ,   Medicare Authorization to Disclose PHI Form (Revised)

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	1,000,000	0	0	0	0
Annual Time Burden (Hours)	250,000	250,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/21/2007

---