Form CMS - 10106 CMS - 10106 Medicare Authorization to Disclose PHI Form

Medicare
Beneficiary Services:1-800-MEDICARE (1-800-633-4227)
TTY/ TDD:1-877-486-2048

Dear Medicare Beneficiary,

Thank you for your call requesting a Medicare Authorization to Disclose Health Information
form. Enclosed is the form, and instructions to help you complete the form.
This form is used to advise Medicare of the person or persons you have chosen to have access to
your personal health information.
Where to Return Your Completed Authorization Form:
After you complete and sign the authorization form, return it to the address below. PLEASE DO
NOT RETURN YOUR FORM TO THE RETURN ADDRESS ON THE ENVELOPE. This
may cause a delay in processing your form.
Return our form to:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For New York Medicare Beneficiaries ONLY
The New York State Public Health Law protects information that reasonably could identify
someone as having HIV symptoms or infection, and information regarding a person’s contacts.
Because of New York’s laws protecting the privacy of information related to alcohol and drug
abuse, mental health treatment, and HIV, there are special instructions for how you, as a New
York resident, should complete this form.
•
•

For question 2A, check the box for Limited Information, even if you want to authorize
Medicare to release any and all of your personal health information.
Then proceed to question 2B.

Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044

Instructions for Completing Section 2B of the Authorization Form:
Please select one of the following options.
•

•

Option 1 To include all information, in the space provided, write: “all information,
including information about alcohol and drug abuse, mental health treatment, and HIV”.
Proceed with the rest of the form.
Option 2 To exclude the information listed above, write “Exclude information about
alcohol and drug abuse, mental health treatment and HIV” in the space provided. You
may also check any of the remaining boxes and include any additional limitations in the
space provided. For example, you could write “payment information”. Then proceed with
the rest of the form.

If you have any questions or need additional assistance, please feel free to call us at
1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.
Sincerely,

1-800-MEDICARE
Customer Service Representative
Encl.

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By law, Medicare must have your written permission (an “authorization”) to use or give out your
personal medical information for any purpose that isn’t set out in the privacy notice contained in
the Medicare & You handbook. You may take back (“revoke”) your written permission at any
time, except if Medicare has already acted based on your permission.
If you want 1-800-MEDICARE to give your personal health information to someone other than
you, you need to let Medicare know in writing.
If you are requesting personal health information for a deceased beneficiary, please include a
copy of the legal documentation which indicates your authority to make a request for
information. (For example: Executor/Executrix papers, next of kin attested by court documents
with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a
court stamp and judge's signature, or personal representative papers with a court stamp and
judge's signature.) Also, please explain your relationship to the beneficiary.
Please use this step by step instruction sheet when completing your “1-800-MEDICARE Authorization
to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure
timely processing.
1. Print the name of the person with Medicare.
Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card,
including any letters (for example, 123456789A).
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.
2. This section tells Medicare what personal health information to give out. Please check a box in
2a to indicate how much information Medicare can disclose. If you only want Medicare to give
out limited information (for example, Medicare eligibility), also check the box (es) in 2b that
apply to the type of information you want Medicare to give out.
3. This section tells Medicare when to start and/or when to stop giving out your personal health
information. Check the first box if you don’t’ want to limit the time frame for which Medicare
can give out your information, or check the second box and fill in dates if you want Medicare to
only give out information for specific time.
4. Medicare will give your personal health information to the person(s) or organization(s) you fill in
here. You may fill in more than one person or organization. If you designate an organization,
you must also identify one or more individuals in that organization to whom Medicare may
disclose your personal health information.
5. The person with Medicare or his/her personal representative must sign their name, fill in the date,
and provide the phone number and address of the beneficiary.

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If you are a personal representative of the person with Medicare, check the box and also provide
your address and phone number, as well as your relationship to the beneficiary. Attach a copy of
the paperwork that shows you can act for that person (for example, Power of Attorney).
6. Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.
7. If, in the future, you change your mind and don't want Medicare to give out your personal health
information, write to the address shown under number six on the authorization form and tell
Medicare. Your letter will revoke your authorization and Medicare will no longer give out your
personal health information (except for the personal health information Medicare has already
given out based on your permission).

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You should make a copy of your signed authorization for your records before mailing
it to Medicare.
Medicare Authorization to Disclose Personal Health Information

Use this form to ask Medicare to give out (disclose) your personal health information.

________________
1. Print Name

______________

__________

Medicare Number
Date of Birth
(Beneficiary’s first and last name) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)

2. Medicare will only disclose the personal health information you want disclosed.
2A: Check only one box below to tell Medicare the specific personal health
information you want disclosed:
Any Information (go to question 3)
Limited Information (go to question 2b)
2B: Complete only if you selected “limited information”. Check all that apply:
Information about your Medicare eligibility
Information about your Medicare claims
Information about plan enrollment (e.g. drug or MA Plan)
Information about premium payments
Other Specific Information (please write below; for example, payment
information)
___________________________________________________
3. Check only one box below indicating how long Medicare can use this
authorization to disclose your personal health information (subject to
applicable law—for example, your State may limit how long Medicare may give
out your personal health information):
Disclose my personal health information indefinitely.

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Disclose my personal health information for a specified period only
beginning: (mm/dd/yyyy) __________ and ending: (mm/dd/yyyy) __________
4. Fill in the name and address of the person(s) or organization(s) to whom you
want Medicare to disclose your personal health information. Please provide the
specific name of the person(s) for any organization you list below:
1.
Name:
Address
2.
Name:
Address:
3.
Name:
Address:
5.
I authorize Medicare to disclose my personal health information listed
above to the person(s) or organization(s) I have named on this form. I
understand that my personal health information may be re-disclosed by the
person(s) or organization(s) and may no longer be protected by law.
____________________________________________

Signature

__________________________________

Telephone Number

_______________________

Date (mm/dd/yyyy)

Print the Beneficiary’s Address (Street Address, City, State, and ZIP)
_____________________________________________________________
_____________________________________________________________
Check here if you are signing as a personal representative and complete
below. Please attach the appropriate documentation (for example, Power of
Attorney). This only applies if someone other than the person with Medicare
signed above.
Print the Personal Representative’s Address (Street Address, City, State, and ZIP)
____________________________________________________________________
____________________________________________________________________

Telephone Number of Personal Representative: ________________________
Personal Representative’s relationship to the beneficiary: ________________
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6. Send the completed, signed authorization to:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
7. Note:
You have the right to take back (“revoke”) your authorization at any time, in
writing, except to the extent that Medicare has already acted based on your
permission. If you would like to revoke your authorization, send a written request
to the address shown above.
Your authorization or refusal to authorize disclosure of your personal health
information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0930. The time required to complete this
information collection is estimated to average15 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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