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

OMB 0938-0930

OMB 0938-0930

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 2021-06-30 and can be found here.


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