Information To Help You Fill Out The (Page 5 of 5) in pdf

Information To Help You Fill Out The Page 5

6. Send the completed, signed authorization to:

Medicare BCC, Written Authorization Dept.

PO Box 1270

Lawrence, KS 66044

7. 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 your authorization, send a written request to the address shown

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.

Print Form

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.

Information To Help You Fill Out The Page 5