Medicare Authorization to Disclose Personal Health Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0930 can be found here:

Documents and Forms

Document Name Document Type
Form CMS - 10106 Medicare Authorization to Disclose Personal Health Information Form and Instruction
CMS - 10106 Medicare Authorization to Disclose PHI Form CMS-10106. English Version - Form and Instructions.pdf Form and Instruction
CMS - 10106 (Spani Medicare Authorization to Disclose PHI Form CMS-10106. Spanish Version - Form and Instructions.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Authorization to Disclose Personal Health Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS - 10106	Medicare Authorization to Disclose PHI Form	CMS-10106. English Version - Form and Instructions.pdf		No		Fillable Fileable
Form and Instruction	CMS - 10106 (Spanish Version)	Medicare Authorization to Disclose PHI Form	CMS-10106. Spanish Version - Form and Instructions.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,000,000	1,000,000
Annual IC Time Burden (Hours)	250,000	250,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.