Form CMS-10106 1-800-MEDICARE Authorization to Disclose Personal Health

Medicare
Beneficiary Services:1-800-MEDICARE (1-800-633-4227)
TTY/ TDD:1-877-486-2048

This form is used to advise Medicare of the person or persons you have chosen to have access to your
personal health information.
Where to Return Your Completed Authorization Forms:
After you complete and sign the authorization form, return it to the address below:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For New York Medicare Beneficiaries ONLY
The New York State Public Health Law protects information that reasonably could identify someone as
having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's
laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and
HIV, there are special instructions for how you, as a New York resident, should complete this form.


For question 2A, check the box for Limited Information, even if you want to authorize Medicare
to release any and all of your personal health information.

 Then proceed to question 2B.

Instructions for Completing Section 2B of the Authorization Form:
Please select one of the following options.
 Option 1 To include all information, in the space provided, write: "all information, including
information about alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest
of the form.


Option 2 To exclude the information listed above, write "Exclude information about alcohol and
drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the
remaining boxes and include any additional limitations in the space provided. For example, you
could write "payment information". Then proceed with the rest of the form.

If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048.
Sincerely,

1-800-MEDICARE
Customer Service Representative

Encl.

Information to Help You Fill Out the
“1-800-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 isn't set out in the privacy notice
contained in the Medicare & You handbook. You may take back (“revoke”) your written
permission at any time, except if Medicare has already acted based on your permission.
If you want 1-800-MEDICARE to give your personal health information to someone other than
you, you need to let Medicare know in writing.
If you are requesting personal health information for a deceased beneficiary, please include a
copy of the legal documentation which 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 with a court stamp and
judge's signature.) Also, please explain your relationship to the beneficiary.

Please use this step by step instruction sheet when completing your “1-800-MEDICARE
Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections
of the form to ensure timely processing.
1. Print the name of the person with Medicare.

Print the Medicare number exactly as it is shown on the red, white, and blue Medicare
card, including any letters (for example, 123456789A).
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.
2. This section tells Medicare what personal health information to give out. Please check a
box in 2a to indicate how much information Medicare can disclose. If you only want
Medicare to give out limited information (for example, Medicare eligibility), also check
the box(es) in 2b that apply to the type of information you want Medicare to give out.
3. This section tells Medicare when to start and/or when to stop giving out your personal
health information. Check the box that applies and fill in dates, if necessary.
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.

5. The person with Medicare or personal representative must sign their name, fill in the date,
and provide the phone number and address of the person with Medicare.

If you are a personal representative of the person with Medicare, check the box, provide
your address and phone number, and attach a copy of the paperwork that shows you can
act for that person (for example, Power of Attorney).
6. Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.
7. If you change your mind and don't want Medicare to give out your personal health
information, write to the address shown under number six 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).

You should make a copy of your signed authorization for your records before mailing it to
Medicare.

1-800-MEDICARE Authorization to Disclose Personal Health Information
Use this form if you want 1-800-MEDICARE to give your personal health information to
someone other than you.

1. Print Name

Medicare Number

Date of Birth

(First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)

2. Medicare will only disclose the personal health information you want disclosed.
2A: Check only one box below to tell Medicare the specific personal health
information you want disclosed:
Limited Information (go to question 2b)
Any Information (go to question 3)

2B: Complete only if you selected “limited information”. Check all that apply:
Information about your Medicare eligibility
Information about your Medicare claims
Information about plan enrollment (e.g. drug or MA Plan)
Information about premium payments
Other Specific Information (please write below; for example, payment information)

3. Check only one box below indicating how long Medicare can use this authorization
to disclose your personal health information (subject to applicable law—for example,
your State may limit how long Medicare may give out your personal health information):
Disclose my personal health information indefinitely
Disclose my personal health information for a specified period only
beginning: (mm/dd/yyyy)
and ending: (mm/dd/yyyy)

4. Fill in the name and address of the person or organization to whom you want
Medicare to disclose your personal health information. Please provide the specific
name of the person for any organization you list below. If you would like to
authorize any additional individuals or organizations, please add those to the back
of this form.
Name:
Address:
Name:
Address:
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 in
number 6 below.
5.

I authorize 1-800-MEDICARE to disclose my personal health information listed
above to the person(s) or organization(s) I have named on this form. I
understand that my personal health information may be re-disclosed by the
person(s) or organization(s) and may no longer be protected by law.

Signature

Telephone Number

Date (mm/dd/yyyy)

Print the address of the person with Medicare (Street Address, City, State, and ZIP)

Check here if you are signing as a personal representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney).
This only applies if someone other than the person with Medicare signed above.
Print the Personal Representative's Address (Street Address, City, State, and ZIP)

Telephone Number of Personal Representative:
Personal Representative's Relationship to the Beneficiary:

6. Send the completed, signed authorization to:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
Note: Your authorization or refusal to authorize disclosure of your personal health
information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.

Print Form

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 0938-0930. The time required to complete
this information collection is estimated to average 15 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.