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

ICR 202206-0938-013

OMB: 0938-0930

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
0938-0930 202206-0938-013
Received in OIRA 201803-0938-007
HHS/CMS OC
Medicare Authorization to Disclose Personal Health Information (CMS-10106)
Reinstatement without change of a previously approved collection   No
Regular 06/10/2022
  Requested Previously Approved
36 Months From Approved
1,000,000 0
250,000 0
0 0

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.

PL: Pub.L. 104 - 191 164.508 Name of Law: Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
  
None

Not associated with rulemaking

  87 FR 14536 03/15/2022
87 FR 35218 06/09/2022
No

  Total Request 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
No
No
There are no program changes but the overall burden has decreased due to a change in the agency estimated number of respondents.

$5,750,000
No
    No
    No
No
No
No
No
William Parham 4107864669

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/10/2022


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