Document
CMS 10106 Medicare Authorization to Disclose Personal Health Information Form
ICR 202305-0938-012 · OMB 0938-0930 · Object 132065001.
This document may belong to an older filing. More recent activity for OMB 0938-0930:
Document Viewer [docx]
Document Metadata
| File Type | application/octet-stream |
|---|---|
| File Title | CMS 10106 Medicare Authorization to Disclose Personal Health Information Form |
| Subject | Medicare Authorization to Disclose Personal Health Information Form |
| Keywords | CMS, 10106, Medicare, Authorization, to, Disclose, Personal, Health, Information, Form, December, 2021 |
| Author | Centers for Medicare and Medicaid Services |
| Last Modified By | Writer |
| File Modified | 2023-05-22 |
| File Created | 2026-08-13 |
| Conversion State | complete |