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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)

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)

3. Check only one box below indicating how long Medicare can use this authorization

to disclose your personal health information (subject to applicable law—for example,

your State may limit how long Medicare may give out your personal health information):

Disclose my personal health information indefinitely

Disclose my personal health information for a specified period only

beginning: (mm/dd/yyyy)

and ending: (mm/dd/yyyy)

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