Information Collection

Medicare Authorization to Disclose Personal Health Information

IC 8778 under ICR 201803-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Medicare Authorization to Disclose Personal Health Information	Form and Instruction
CMS-10106 Medicare Authorization to Disclose Personal Health Infor CMS-10106.Instrument (English).docx	Form and Instruction
CMS-10106 Medicare Authorization to Disclose Personal Health Infor CMS-10106.Instrument (Spanish).docx	Form and Instruction
CMS-10106.Crosswalk of Revisions.xls CMS-10106.Crosswalk of Revisions	IC Document

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	Medicare Authorization to Disclose Personal Health Information (Spanish)	CMS-10106.Instrument (Spanish).docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-10106	Medicare Authorization to Disclose Personal Health Information	CMS-10106.Instrument (English).docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Beneficiary Database

FR Citation: 83 FR 6591

Number of Respondents: 2,000,000

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,000,000	701,671	1,298,329
Annual IC Time Burden (Hours)	500,000	175,418	324,582
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10106.Crosswalk of Revisions	CMS-10106.Crosswalk of Revisions.xls	03/26/2018

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