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

ICR 202305-0938-012

OMB: 0938-0930

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10106 Medicare Authorization to Disclose Personal Health Information Form and Instruction	Modified
0938-0930 (CMS 10601) - Non Substantive Change Request Memo (5-12-23).docx Justification for No Material/Nonsubstantive Change	2023-05-22
CMS-10106_Supporting_Statement_Part_A (final).docx Supporting Statement A	2022-06-10

IC Document Collections

IC ID	Document Title	Status
8778	Medicare Authorization to Disclose Personal Health Information Form and Instruction	Modified