Medicare Authorization to Disclose Personal Health Information (CMS-10106)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10106 Authorization to Disclose Personal Health Information Form (Spanish)	Form and Instruction	Modified	Available
Form CMS-10106 Authorization to Disclose Personal Health Information Form	Form and Instruction	Modified	Available
Form CMS-10106 Medicare Authorization to Disclose Personal Health Information (Spanish)	Form and Instruction	Modified	Available
Form CMS-10106 Medicare Authorization to Disclose Personal Health Information	Form and Instruction	Modified	Repair queued
CMS-10106_Supporting_Statement_Part_A (final).docx	Supporting Statement A	Uploaded 2022-06-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8778	Medicare Authorization to Disclose Personal Health Information	Form and Instruction	Modified	Authorization to Disclose Personal Health Information Form (Spanish)
8778	Medicare Authorization to Disclose Personal Health Information	Form and Instruction	Modified	Authorization to Disclose Personal Health Information Form
8778	Medicare Authorization to Disclose Personal Health Information	Form and Instruction	Modified	Medicare Authorization to Disclose Personal Health Information (Spanish)
8778	Medicare Authorization to Disclose Personal Health Information	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0930	ICR Reference No: 202206-0938-013
Status: Historical Active	Previous ICR Reference No: 201803-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: OC
Title: Medicare Authorization to Disclose Personal Health Information (CMS-10106)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/04/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/10/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2025	36 Months From Approved
Responses	1,000,000	0	0
Time Burden (Hours)	250,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Unless permitted or required by law, the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule prohibit covered entities from disclosing an individual's protected health information to a third party without a valid privacy authorization. The authorization must include specified core elements and certain statements. Medicare beneficiaries will use the "Medicare Authorization to Disclose Personal Health Information" to authorize Medicare to diclose their protected health information to a third party.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 164.508 Name of Law: Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 14536	03/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 35218	06/09/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Authorization to Disclose Personal Health Information	CMS-10106 , CMS-10106, CMS-10106	Medicare Authorization to Disclose Personal Health Information (Spanish) ,   Authorization to Disclose Personal Health Information Form ,   Authorization to Disclose Personal Health Information Form (Spanish)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	0	0	0	-1,000,000	2,000,000
Annual Time Burden (Hours)	250,000	0	0	0	-250,000	500,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There are no program changes but the overall burden has decreased due to a change in the agency estimated number of respondents.

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Annual Cost to Federal Government: $5,750,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/10/2022

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