Medicare Authorization to Disclose Personal Health Information

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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 (Spanish).docx Form and Instruction
CMS-10106 Medicare Authorization to Disclose Personal Health Infor CMS-10106.Instrument (Spanish).docx Form and Instruction
CMS-10106 Authorization to Disclose Personal Health Information Fo CMS-10106-C-final.pdf Form and Instruction
CMS-10106 Authorization to Disclose Personal Health Information Fo CMS-10106-C-final.pdf Form and Instruction
CMS-10106 Authorization to Disclose Personal Health Information Fo CMS-10106-SP-C-FINAL.pdf Form and Instruction
CMS-10106 Authorization to Disclose Personal Health Information Fo CMS-10106-SP-C-FINAL.pdf Form and Instruction
CMS-10106.Crosswalk of Revisions.xls CMS-10106.Crosswalk of Revisions IC Document
CMS-10106.Crosswalk of Revisions.xls CMS-10106.Crosswalk of Revisions IC Document

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	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	Authorization to Disclose Personal Health Information Form	CMS-10106-C-final.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10106	Authorization to Disclose Personal Health Information Form (Spanish)	CMS-10106-SP-C-FINAL.pdf	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: 1,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,000,000	-1,000,000	2,000,000
Annual IC Time Burden (Hours)	250,000	-250,000	500,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.