Information Collection

Medicare Authorization to Disclose Personal Health Information

IC 8778 under ICR 201502-0938-008 · OMB 0938-0930.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0930 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10106 1-800-MEDICARE Authorization to Disclose Personal Health Information Medicare Authorization to Disclose Personal Health Information	Form and Instruction
Form CMS-10106 (Spanish Language Version) 1-800-MEDICARE Authorization to Disclose Personal Health Information Medicare Authorization to Disclose Personal Health Information	Form and Instruction
CMS-10106 1-800-MEDICARE Authorization to Disclose Personal Health CMS10106.pdf	Form and Instruction
CMS-10106 (Spanish Language Version) 1-800-MEDICARE Authorization CMS10106-S.PDF	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10106				Yes	No	Fillable Printable
Form and Instruction	CMS-10106				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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,298,329	1,298,329
Annual IC Time Burden (Hours)	324,582	324,582
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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