Medicare Authorization to Disclose Personal Health Information

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

OMB: 0938-0930

IC ID: 8778

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Medicare Authorization to Disclose Personal Health Information
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10106 Authorization to Disclose PHI (SPANISH) 0938-0930 (CMS 10601) - Authorization to Disclose PHI (SPANISH).docx Yes No Fillable Fileable
Form and Instruction CMS-10106 Authorization to Disclose PHI (ENGLISH) 0938-0930 (CMS 10601) - Authorization to Disclose PHI (ENGLISH).docx Yes No Fillable Fileable

Health Health Care Services

Medicare Beneficiary Database  83 FR 6591

1,000,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,000,000 0 0 0 0 1,000,000
Annual IC Time Burden (Hours) 250,000 0 0 0 0 250,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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