Information to Help You Fill Out the

Information to Help You Fill Out the

“Medicare Authorization to Disclose Personal Health Information” Form

By law, Medicare must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that is not included in the privacy notice contained in the Medicare & You handbook by completing the form. You may take back (“revoke”) your written permission at any time, except if Medicare has already acted based on your permission.

If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing.

Please use this step by step instruction sheet when completing the MEDICARE Authorization to Disclose Personal Health Information form. Be sure to complete all sections of the form to ensure timely processing.

Section 1

1. Print the name of the person with Medicare, exactly as it appears on the red, white, and blue Medicare card.

2. Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 000000000A).

3. Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.

Section 2 This section tells Medicare what personal health information to give out. Please check either 2A or 2B in Section 2 to indicate how much information Medicare can disclose.

Check Box 2A if you want Medicare to release any information.

Check Box 2B if you only want Medicare to give out limited information (for example, Medicare eligibility).You must select the type of information you want Medicare to give out by checking the circle(s) under 2B.

Box 2C must be completed by New York Residents. Please see instructions below for completing section 2C.

Instructions for NY Residents completing Section 2C of the Authorization Form:

Please select one of the following options on the form to authorize Medicare to release the following information.

• Check box (a) – If you select box a, Medicare will release all information. This will include information about alcohol and drug abuse, mental health treatment, and HIV.

• Check box (b) – If you select box b, Medicare will NOT release any about alcohol and drug abuse, mental health treatment and HIV.

You should only check a OR b. Do not select both.

Section 3 This section tells Medicare when to start and/or when to stop giving out your personal health information.

Check the first box (a) if you do not want to limit the timeframetimeframe, for which Medicare can give out your information,

OR

Check the second box (b) and fill in dates if you want Medicare to only give out information for specific time.

You MUST provide a start and stop date if selecting box (b).

You should only check a or b. Do not select both.

Section 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.

Section 5 The person with Medicare must sign his/her name, fill in the date, and provide the phone number and address of the person with Medicare.

If you are the personal representative for the person with Medicare, you must complete section 5 for the beneficiary and complete section 6.

Section 6 If you are signing on behalf of the person with Medicare, check the box in section 6 and also provide your signature, address and phone number Attach a copy of the paperwork that shows you can act for that person (for example, power of attorney or executorship). Please review your state laws for the requirements of a valid power of attorney.

If you are requesting personal health information for a Medicare recipient who is now deceased, please complete all sections of the form and include a copy of the legal documentation that 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 and judge’s signature.) Please review your state laws for the requirements of a valid executorship.

Revoke authorization

In the future, if you, the person with Medicare, change your mind and do not want Medicare to give out your personal health information, write to the address shown 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).