Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information Page 3
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8Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0930
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,
including any letters (for example, 000000000A).
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. 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 07/15)
Instructions
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