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CMS10106 CMS10106

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Medicare
Beneficiary Services:1-800-MEDICARE (1-800-633-4227)
TTY/ TDD:1-877-486-2048
This form is used to advise Medicare of the person or persons you have chosen to have access to your
personal health information.
Where to Return Your Completed Authorization Forms:
After you complete and sign the authorization form, return it to the address below:
Medicare CCO, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For New York Medicare Beneficiaries ONLY
The New York State Public Health Law protects information that reasonably could identify someone as
having HIV symptoms or infection, and information regarding a person's contacts. Because of New
York's laws protecting the privacy of information related to alcohol and drug abuse, mental health
treatment, and HIV, there are special instructions for how you, as a New York resident, should complete
this form.
• For question 2A, check the box for Limited Information, even if you want to authorize
Medicare to release any and all of your personal health information.
• Then proceed to question 2B. You may also check any of the remaining boxes and include any
additional limitations in the space provided. For example, you could write "payment information".
Instructions for Completing Section 2C of the Authorization Form:
Please select one of the following options.
• Option 1 To include all information, check the box: "All information, including information about
alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest of the form.
• Option 2 To exclude the information listed above, check the box "Exclude information about
alcohol and drug abuse, mental health treatment, and HIV". Then proceed with the rest of the form.
If you have any questions or need additional assistance, please feel free to call us at 1-800-
MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Sincerely,
1-800-MEDICARE
Customer Service Representative
Encl.
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
Information to Help You Fill Out the
“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form
By law, Medicare must have your written permission (an “authorization”) to use or give out your
personal medical information for any purpose that isn't set out in the privacy notice contained in the
Medicare & You handbook. You may take back (“revoke”) your written permission at any time, except
if Medicare has already acted based on your permission.
If you want 1-800-MEDICARE to give your personal health information to someone other than you,
you need to let Medicare know in writing.
If you are requesting personal health information for a deceased beneficiary, please include a
copy of
the legal documentation which indicates your authority to make a request for 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.) Also, please explain your
relationship to the beneficiary.
Please use this step by step instruction sheet
when completing your “1-800-MEDICARE Authorization
to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure
timely processing.
1. Print the name of the person with Medicare.
Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card.
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.
2. This section tells Medicare what personal health information to give out. Please check a box in
2A to indicate how much information Medicare can disclose. If you only want Medicare to
give out limited information (for example, Medicare eligibility), also check the box(es) in 2B
that apply to the type of information you want Medicare to give out. Box 2C must be completed
by New York Residents.
3. This section tells Medicare when to start and/or when to stop giving out your personal health
information. Check the box that applies and fill in dates, if necessary.
4. This section tells Medicare the reason for disclosure.
5. Medicare will give your personal health information to the person(s) or organization(s) you fill in
here. You may fill in more than one person or organization.
If you designate an organization, you must also identify one or more individuals in that
organization to whom Medicare may disclose your personal health information.
Form CMS-10106 (Rev 03/19)
Instructions
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
6. The person with Medicare or personal representative must sign their name, fill in the date, and
pr
ovide the phone number and address of the person with Medicare
.
If you ar
e a personal representative of the person with Medicare, check the box, provide you
r
a
ddress and phone number, and attach a copy of the paperwork that shows you can act for tha
t
pe
rson (for example, Power of Attorney)
.
7. Send your completed, signed authorization to Medicare at the address shown here on your
a
uthorization form
.
8. If you change your mind and don't want Medicare to give out your personal health information,
wr
ite to the address shown under number seven on the authorization form and tell Medicare
.
Y
our letter will revoke your authorization and Medicare will no longer give out your persona
l
he
alth information (except for the personal health information Medicare has already given
out
ba
sed on your permission)
.
You should make a copy of your signed authorization for your records before mailing it to
Medicare.
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.
Form CMS-10106 (Rev 03/19)
Instructions
___________________________________
_____________________
___________
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
1-800-MEDICARE Authorization to Disclose Personal Health Information
Use this form if you want 1-800-MEDICARE to give your personal health information to someone
other than you.
Print Name
Medicare Number
Date of Birth
(First and last name of the person with Medicare)
(Exactly as shown on the Medicare Card)
(mm/dd/yyyy)
2.
Medicare will only disclose the personal health information you want disclosed.
2A: Check only one box below to tell Medicare the specific personal health information you
want disclosed:
Limited Information (go to question 2b)
Any Information (go to question 3)
2B: Complete only if you selected “limited information”. Check all that apply:
Information about your Medicare eligibility
Information about your Medicare claims
Information about plan enrollment (e.g. drug or MA Plan)
Information about premium payments
Other Specific Information (please write below; for example, payment information)
2C: NY Residents Only, this section must be completed.
Please select one of the following options: (Please check only one box.)
Include all information. This includes information about alcohol and drug abuse, mental
health treatment, and HIV.
OR
Exclude information about alcohol and drug abuse, mental health treatment, and HIV.
Form CMS-10106 (Rev 03/19)
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
3.
Check only one box below indicating how long Medicare can use this authorization to disclose
you
r personal health information (subject to applicable law—for example, your State may limi
t
how
long Medicare may give out your personal health information)
:
D
isclose my personal health information indefinitely
Disclose my personal health information for a specified period only
beginning: ____________________(mm/dd/yyyy) and ending: _________________(mm/dd/yyyy)
4. Fill in the reason for the disclosure (you may write "at my request"):
5.
Fill in the name and address of the person or organization to whom you want
Medicare
to
disclose your personal health information. Please provide the specific
name of the person f
or
an
y organization you list below. If you would like to authorize any additional individuals o
r
or
ganizations, please add those to the back of this form
.
Name ______________________________________________________________________
Address ______________________________________________________________________
Name ______________________________________________________________________
Address ______________________________________________________________________
Form CMS-10106 (Rev 03/19)
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except
to the extent that Medicare has already acted based on your permission. To revoke authorization,
send a written request to the address noted below. Your authorization or refusal to authorize disclosure
of your personal health information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.
6.
I authorize 1-800-MEDICARE to disclose my personal health information listed above to
the person(s) or organization(s) I have named on this form. I understand that my
personal health information may be re-disclosed by the person(s) or organization(s) and
may no longer be protected by law.
Signature
Telephone Number
Date (mm/dd/yyyy)
Print the address of the person with Medicare (Street Address, City, State, and ZIP)
Check here if you are signing as a personal representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney). This only
applies if someone other than the person with Medicare signed above.
Print the Personal Representative's Address (Street Address, City, State, and ZIP)
Telephone
Number
of
Personal
Representative:
Personal
Representative's
Relationship to
the
Beneficiary:
Form CMS-10106 (Rev 03/19)
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services OMB No. 0938-0930
Expiration Date: 7/31/2021
7.
Se
nd the completed, signed authorization to
:
M
edicare CCO, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the
extent that Medicare has already acted based on your permission. If you would like to revoke
authorization, send a written request to the address noted above.
Your authorization or refusal to authorize disclosure of your personal health information will have no
effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services
you receive.
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.
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.
Form CMS-10106 (Rev 03/19)
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Completed 18 September 2019

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