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

Unless permitted or required by law, the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule prohibit covered entities from disclosing an individual's protected health information to a third party without a valid privacy authorization. The authorization must include specified core elements and certain statements. Medicare beneficiaries will use the "Medicare Authorization to Disclose Personal Health Information" to authorize Medicare to diclose their protected health information to a third party.

The latest form for Medicare Authorization to Disclose Personal Health Information (CMS-10106) expires 2029-03-31 and is listed under ICR 202511-0938-006.