Cms-10106

0938-0930

Justification of Non-material Modification

CMS-10106: Medicare Authorization to Disclose Personal Health Information

The following changes were made to the Instruction page of CMS-10106 Form to clarify how the form should be used by people who are requesting personal health information (PHI) for deceased beneficiaries. There will be no additional changes to the burden. We feel that offering clarification in the instructions will simplify the process and minimize the response time for Medicare.    

The following paragraph is taken directly from the revised collection instrument. Please see the attached document in track changes format.

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.