Specific Instructions
A. Background
This “Medicare Authorization to Disclose Personal Health Information” will be used by Medicare beneficiaries to authorize Medicare to disclose their protected health information to a third party. In January 2004, The Authorization was published in the Federal Register for a 60-day comment period and received no comments. In July 2004, the authorization form was beneficiary tested. Minor changes were made and brief instructions were added to the form to make it more beneficiary-friendly.
B. Justification
1 . Need and Legal Basis
Unless permitted or required by law, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (§ 164.508) prohibits Medicare (a HIPAA covered entity) from disclosing an individual’s protected health information without a valid authorization. In order to be valid, an authorization must include specified core elements and statements. Medicare will make available to Medicare beneficiaries a standard, valid authorization to enable beneficiaries to request the disclosure of their protected health information. This standard authorization will simplify the process of requesting information disclosure for beneficiaries and minimize the response time for Medicare.
2. Information Users
The completed authorization will allow Medicare to disclose an individual’s personal health information to a third party at the individual’s request.
3. Improved Information Technology
Beneficiaries will submit the “Medicare Authorization to Disclose Personal Health Information” in paper. At this time, Medicare does not have the capability to permit the submission of electronic authorizations.
4. Duplication of Similar Information
This is a request to extend an existing, standard Medicare authorization that includes the core elements and statements required by HIPAA.
5. Small Businesses
Small businesses are not affected by this collection.
6. Less Frequent Collection
Providing a valid authorization form to Medicare beneficiaries is good customer service. The Medicare authorization form will simplify the process for beneficiaries and quicken Medicare’s response time.
7. Special Circumstances
Not applicable.
8. Federal Register Notice/Outside Consultation
The 60-day FR notice for this collection published on June 8, 2007.
9. Payments/Gifts To Respondents
Not applicable.
10. Confidentiality
As required by HIPAA, Medicare sends all Medicare beneficiaries a Notice of Privacy Practices (included in the Medicare & You Handbook and on the medicare.gov Web site). The Notice of Privacy Practices assures Medicare beneficiaries that their personal health information is protected and informs beneficiaries of their privacy rights. Medicare has added HIPAA-required privacy protection language to all contracts with business associates. As required by the Privacy Act, Medicare publishes systems of records notices in the Federal Register that describe the data in each system and to whom Medicare may disclose the information. A Privacy Act Statement assuring confidentiality is given to individuals when their information is collected.
Unless permitted or required by law, Medicare only discloses an individual’s protected information with a valid authorization. Medicare assures beneficiaries of the confidentiality of their information by requiring the authorization include the core elements and statements required by HIPAA. The core elements specify what information is to be disclosed and to whom.
11. Sensitive Questions
Not applicable.
12. Burden Estimate (Total Hours & Wages)
Number of respondents and frequency of response: There are approximately 39 million Medicare beneficiaries. Beneficiaries contact Medicare contractors (Fiscal Intermediaries, Carriers, Call Centers, and Durable Medical Equipment Regional Carriers) to request the disclosure of their Medicare protected health information. To estimate the number of Medicare beneficiaries who may submit authorizations on an annual basis, Medicare asked a sample of each type of Medicare contractor to provide an estimate of the number of authorizations the contractor receives annually. The estimate for each contractor type was then multiplied by the number of that type of contractor. Medicare estimates one million authorizations will be submitted per year.
Annual hour burden: Processing written consents and authorizations is a customary and usual business practice for Medicare. The standard Medicare authorization will not increase the burden for Medicare. It will take Medicare contractors between 10 minutes and 2 weeks to process the authorization.
Burden hour and cost to respondents for the collection of information: There will be no cost to Medicare beneficiaries to request, complete, submit, or have processed the Medicare authorization form. It should take approximately 15 minutes for a beneficiary to complete the Medicare authorization form. 15 minutes times 1 million beneficiaries equals 250,000 hours.
13. Capital Costs
Not applicable.
14. Cost to the Federal Government
None.
15. Program Changes
There are no program changes to the collection.
16. Publication and Tabulation Dates
Not applicable.
17. Expiration Date
Medicare beneficiaries contact Medicare contractors (Medicare Beneficiary Call Center, Medicare Administrative Contractors, etc.) to ask Medicare to disclose their information to third parties. When beneficiaries make such a request, Medicare contractors will send beneficiaries a blank “Medicare Authorization to Disclose Personal Health Information.” The Beneficiary Call Center and other contractors may customize the form with the appropriate return address prior to sending to the beneficiary. Therefore, Medicare will not display the expiration date on the authorization form.
18. Certification Statement
There are no exceptions to the certification statement.
C. Collections of Information Employing Statistical Methods -- Item 12 on OMB 83-I Part 1 is checked “No.” Not applicable. 2. Not Applicable. 3. Not Applicable. 4. Not Applicable. 5. Not Applicable
| File Type | application/msword |
| File Title | HCFA |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2007-05-31 |
| File Created | 2007-05-31 |