Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information

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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 BCC, 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".

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