Information To Help You Fill Out The


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.
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.
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, including any letters (for example, 123456789A).
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.
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.
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.
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.
The person with Medicare or personal representative must sign their name, fill in the date,
and provide the phone number and address of the person with Medicare.
If you are a personal representative of the person with Medicare, check the box, provide
your address and phone number, and attach a copy of the paperwork that shows you can
act for that person (for example, Power of Attorney).
Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.


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