Medicare Authorization to Disclose Personal Health Information

Medicare Authorization to Disclose Personal Health Information

OMB: 0938-0930

IC ID: 8778

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Medicare Authorization to Disclose Personal Health Information
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS-10106 Instructions.pdf Yes No Printable Only
Form and Instruction CMS-10106 Medicare Authorization to Disclose Personal Health Information CMS-10106 Authorization Form.pdf Yes No Fillable Printable

Health Health Care Services

 

1,298,329 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,298,329 0 0 294,329 1,004,000 0
Annual IC Time Burden (Hours) 324,582 0 0 73,582 251,000 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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