Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information Page 4
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8Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0930
5. 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).
6. Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.
7. If you change your mind and don't want Medicare to give out your personal health information,
write to the address shown under number six on the authorization form and tell Medicare. Your
letter will revoke your authorization and Medicare will no longer give out your personal health
information (except for the personal health information Medicare has already given out based
on your permission).
You should make a copy of your signed authorization for your records before mailing it to Medicare.
Form CMS-10106 (Rev 07/15)
Instructions
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Parent category: Medical