Form CMS-10106 Authorization to Disclose PHI (English)

Authorization to Disclose Personal Health
Information Release Form
Use this form to give 1-800-MEDICARE permission to share your personal health information with someone
other than you.
You can also use this form to get information for someone who is deceased (if you legally have the right
to that information because you’re an Executor, or you have court documents giving you rights to that
information.)
By law, you must give 1-800-MEDICARE permission in writing before 1-800-MEDICARE can share
any information with someone other than you. For the full list of how 1-800-MEDICARE uses your
information, see the privacy notice in the Medicare & You handbook, or visit Medicare.gov and search
for “privacy practices.”

Submit your form online or by mail
• For faster service, submit this form online by logging in to your secure Medicare.gov account.
• Or, mail your completed and signed authorization form to:
1-800-MEDICARE Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
If you’re requesting personal health information for a deceased person who had Medicare, include a copy
of the legal documentation that gives you the authority to get this information. (For example: Executor/
Executrix papers, next of kin attested by court documents with a court stamp and a judge’s signature,
a Letter of Testamentary or Administration with a court stamp and judge’s signature, or personal
representative papers with a court stamp and judge’s signature.)

How to cancel your Authorization to Disclose
You have the right to change or cancel (“revoke”) your authorization at any time. If you change your mind
later and no longer want us to share your personal health information, write to the address above and tell us.
Your letter will cancel your authorization form, and we’ll no longer share your personal health information
(except for any information we already released based on your original permission).

Get help with this form
If you have questions or need help with this form, call us at 1-800-MEDICARE (1-800-633-4227). TTY users
can call 1-877-486-2048.

Get information in another format
You have the right to get Medicare information in an accessible format, like large print, braille, or
audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit
Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227)
for more information. TTY users can call 1-877-486-2048.
Paperwork Reduction Act: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0930.
The time required to complete this information collection is estimated to average 15 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn.: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. DO NOT
MAIL YOUR COMPLETED FORM TO THIS ADDRESS. If you do, we won’t be able to process your form, and your request to release
your personal health information will be significantly delayed.
Form CMS-10106 (XX/XX)

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB No. 0938-0930

Authorization to Disclose Personal Health Information Release Form
Use this form to give 1-800-MEDICARE permission to share your personal health information with someone
other than you. You can also use this form to get information for someone who is deceased (if you have
legal right to that information because you’re an Executor or have court documents giving you rights to that
information.)

Information about the person with Medicare
First name

Middle name

Last name

Suffix

Date of birth (mm/dd/yyyy)

Medicare Number
Mailing address (number and street, P.O. Box, or route)
City
Phone number (optional)

State

ZIP code

Email address (optional)

Enter the name of each person or organization that can get your personal health information from
1-800-MEDICARE
To share with more than 2 people or organizations, list their name and address on the back of this form.
Person/Organization 1 (full name)
Mailing address (number and street, P.O. Box, or route)
City

State

ZIP code

State

ZIP code

Person/Organization 2 (full name)
Mailing address (number and street, P.O. Box, or route)
City

Choose the information you want 1-800-MEDICARE to share.
Check only one box:
Any information
Limited information 
If you selected “limited information,” let us know the types of personal health information you want
us to share. Check all that apply:
Medicare eligibility
Medicare claims
Health & drug plan enrollment
Premium payments
Other (Write any other information you want shared below. For example, payment information):

Form CMS-10106 (XX/XX)

1

For New York Residents Only
The New York State Public Health Law protects the privacy of information related to alcohol and drug
abuse, mental health treatment, and HIV. Do you give your permission to share this information?
Yes, I give 1-800-MEDICARE permission to share information about alcohol and drug abuse, mental
health treatment, or HIV.
No, I DON’T give 1-800-MEDICARE permission to share information about alcohol and drug abuse, mental
health treatment, or HIV.

How long can 1-800-MEDICARE use this authorization to share your personal health
information*?
Check one:
Share my personal health information indefinitely.
Share my personal health information only for this period of time:
Start date:

  End date:

*Your state may have different limits on how long Medicare can share your personal health information.
Explain why you’re giving 1-800-MEDICARE permission to share your information.
(You can write “At my request.”)

Signature
By signing this form, I authorize 1-800-MEDICARE to share my personal health information listed above to
the person(s) or organization(s) I named on this form. I understand that my personal health information may
be shared by the person(s) or organization(s) and may no longer be protected by law.
Signature

Date signed (mm/dd/yyyy)

Personal Representative Information
Check here if you’re signing as a personal representative and complete the fields below.
Attach a copy of the paperwork that shows you can act for the person (like a Power of Attorney).
Personal representative’s first name

Middle name

Last name

Suffix

Mailing address (number and street, P.O. Box, or route)
City
Phone number

State

ZIP code

Relationship to the person with Medicare

Submit your form online or by mail
• For faster service, submit this form online by logging in to your secure Medicare.gov account.
• Or, mail your completed and signed authorization form to:
1-800-MEDICARE Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
If you’re requesting personal health information for a deceased person who had Medicare, include a copy of
the legal documentation that gives you the authority to get this information.
Form CMS-10106 (XX/XX)