CMS-10106 Medicare Authorization to Disclose Personal Health Infor

OMB no. 0938-0930

Medicare Authorization to Disclose Personal Health Information
Use this form to ask Medicare to give out (disclose) your personal health information to the
individual or organization you choose.
Section 1
___________________________
Print Person with Medicare’s First &
Last Name

_______________________
Medicare Number

______________________
Date of Birth (mm/dd/yyyy)

Print person with Medicare’s first and last name as shown on the Medicare card.
Section 2
Medicare will only disclose the personal health information you want disclosed.
Check () box 2A or 2B. Do not check both boxes.
New York residents must also complete Box 2C.
2A - I want Medicare to release any information.

OR
For limited disclosure of information, check the box 2B below and select the
appropriate information to tell Medicare the specific personal health information
you want disclosed:
2B – I want Medicare to ONLY release the limited information checked below:
Check all that apply.
o Information about your Medicare eligibility
o Information about your Medicare claims
o Information about plan enrollment (e.g. drug or MA plan)
o Information about premium payments
Other specific information printed on the line below. If this box is checked, you must
include a description of information to be released or the request cannot be processed.)

Standard form 10106 (April 2014)

OMB no. 0938-0930

2C - NY Residents Only, this section must be completed.)
Please select one of the following options:
(Please check only one box.)
a) Include all information. This includes information about alcohol and drug abuse,
mental health treatment, and HIV.
OR
b) Exclude information about alcohol and drug abuse, mental health treatment, and
HIV.

Section 3
How long should Medicare release the information to the authorized individuals or
organization? (This is subject to applicable law – for example, your state may limit how long
Medicare may give out your personal health information.)
Check only one box.
a) Disclose my personal health information indefinitely.
OR
b) Disclose my personal health information for a specified period:
______________________ ______________________
Beginning date (mm/dd/yyyy)

Ending date (mm/dd/yyyy)

(If selecting b, you must include a stop and start date or the request cannot be processed.)

Standard form 10106 (April 2014)

OMB no. 0938-0930

Section 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 in the section(s) below.
 If you need to list additional names, you may attach a sheet of paper to this form.
(Include your name and Medicare number on the additional sheet.)
 Please provide the specific name of the person(s) for any organization you listed below:
Name:
Address:
(required)
Name:
Address:
(required)
Name:
Address:
(required)

Section 5
I authorize Medicare to disclose my personal health information listed in section 2 to the
person(s) and/or organization(s) I have named on this form. I understand that my personal
health information may be re-disclosed by the person(s) and/or organization(s) and may no
longer be protected by law.
______________________________
Signature

_____________________
Telephone Number

______________________
Today’s Date (mm/dd/yyyy)

Print the person with Medicare’s current address (street address, city, state and ZIP Code):
___________________________________________________________________________
___________________________________________________________________________

If the person with Medicare signs section 5 above, do not complete section 6.

Standard form 10106 (April 2014)

OMB no. 0938-0930

Section 6 - For Personal Representative Only
Important information: This section should only be completed if someone other than the
person with Medicare signs in section 5.
Check here if you are signing as a personal representative of the person with Medicare
and complete the information below. Please attach the appropriate legal documentation
(for example, Power of Attorney or Executorship). See the instructions on submitting
the appropriate legal documents.
Signature: __________________________________________________________
Print the personal representative’s address (street address, city, state and ZIP Code):
_________________________________________________________________________
_________________________________________________________________________
Personal representative’s telephone number:

______________________________

You should make a copy of your signed authorization for your records before mailing it to
Medicare.
Send the completed, signed authorization to:
Medicare BCC, Written Authorization Dept.
P.O. Box 1270
Lawrence, KS 66044
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 of refusal to authorize disclosure of your personal health information
will have no effect on your enrollment, eligibility or benefits, or the amount Medicare pays
for the health services you receive.

Standard form 10106 (April 2014)

OMB no. 0938-0930

PRA Disclosure Statement
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-XXXX. The time required to complete
this information collection is estimated to average [Insert Time (hours or 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. Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact 1-800-MEDICARE.

Standard form 10106 (April 2014)