Medicare Authorization to Disclose Personal Health Information

ICR 200811-0938-007

OMB: 0938-0930

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2008-11-24
Supporting Statement A
2008-11-25
IC Document Collections
ICR Details
0938-0930 200811-0938-007
Historical Active 200804-0938-003
HHS/CMS
Medicare Authorization to Disclose Personal Health Information
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 05/08/2009
Retrieve Notice of Action (NOA) 11/28/2008
  Inventory as of this Action Requested Previously Approved
03/31/2011 03/31/2011 03/31/2011
1,000,000 0 1,000,000
250,000 0 250,000
0 0 0

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.

PL: Pub.L. 104 - 191 164.508 Name of Law: Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
  
None

Not associated with rulemaking

  72 FR 31839 06/08/2007
72 FR 48646 08/24/2007
Yes

1
IC Title Form No. Form Name
Medicare Authorization to Disclose Personal Health Information CMS - 10106, CMS - 10106 (Spanish Version) Medicare Authorization to Disclose PHI Form ,   Medicare Authorization to Disclose PHI Form

  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
No
No

$0
No
No
Uncollected
Uncollected
No
Uncollected
William Parham 4107864669

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/28/2008


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