Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information Page 5
Download a blank fillable Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0930
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.
1. 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)
2. 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)
__________________________________________________________________
__________________________________________________________________
2C: NY Residents Only, this section must be completed.
Please select one of the following options: (Please check only one box.)
Include all information. This includes information about alcohol and drug abuse, mental
health treatment, and HIV.
OR
Exclude information about alcohol and drug abuse, mental health treatment, and HIV.
Form CMS-10106 (Rev 07/15)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical