Information Collection

Medicare Authorization to Disclose Personal Health Information

IC 8778 under ICR 202511-0938-006 · OMB 0938-0930.

Documents and Forms

Document Name Document Type
Form CMS-10106 Medicare Authorization to Disclose Personal Health Information Form and Instruction
Form CMS-10106 Authorization to Disclose PHI (English) Medicare Authorization to Disclose Personal Health Information Form and Instruction
Form CMS-10106 Authorization to Disclose PHI (Spanish) Medicare Authorization to Disclose Personal Health Information Form and Instruction
CMS-10106 Authorization to Disclose PHI (English) CMS-10106-English-508C.pdf Form and Instruction
CMS-10106 Authorization to Disclose PHI (Spanish) CMS-10106-Spanish-508C.pdf Form and Instruction
CMS-10106 Authorization to Disclose PHI (English) CMS-10106-English-508C.revised clean -3-3-26.pdf Form and Instruction
CMS-10106 Authorization to Disclose PHI (Spanish) CMS-10106-Spanish-508C. revised clean.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Authorization to Disclose Personal Health Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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 (English)	CMS-10106-English-508C.revised clean -3-3-26.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10106	Authorization to Disclose PHI (Spanish)	CMS-10106-Spanish-508C. revised clean.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Beneficiary Database	FR Citation: 83 FR 6591

Number of Respondents: 1,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,000,000	1,000,000
Annual IC Time Burden (Hours)	250,000	250,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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