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Medicare Authorization to Disclose Personal Health Information
Medicare Authorization to Disclose Personal Health Information (CMS-10106)
OMB: 0938-0930
IC ID: 8778
OMB.report
HHS/CMS
OMB 0938-0930
ICR 202305-0938-012
IC 8778
( )
Documents and Forms
Document Name
Document Type
Form CMS-10106
Medicare Authorization to Disclose Personal Health Information
Form and Instruction
CMS-10106 Authorization to Disclose PHI (SPANISH)
0938-0930 (CMS 10601) - Authorization to Disclose PHI (SPANISH).docx
Form and Instruction
CMS-10106 Authorization to Disclose PHI (ENGLISH)
0938-0930 (CMS 10601) - Authorization to Disclose PHI (ENGLISH).docx
Form and Instruction
CMS-10106.Crosswalk of Revisions.xls
CMS-10106.Crosswalk of Revisions
IC Document
Information Collection (IC) Details
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