Information Collection Request
Medicare Authorization to Disclose Personal Health Information (CMS-10106)
ICR 202305-0938-012 · OMB 0938-0930 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0930 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-10106 Medicare Authorization to Disclose Personal Health Information |
Form and Instruction | Modified | Repair queued |
 0938-0930 (CMS 10601) - Non Substantive Change Request Memo (5-12-23).docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-05-22 | Repair queued |
| CMS-10106_Supporting_Statement_Part_A (final).docx |
Supporting Statement A | Uploaded 2022-06-10 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 8778 |  Medicare Authorization to Disclose Personal Health Information |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0930 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202206-0938-013 |
| Agency Tracking No | OC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |