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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10106 Instructions.pdf Instruction
CMS-10106 Medicare Authorization to Disclose Personal Health Infor CMS-10106 Authorization Form.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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,298,329	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

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