Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information Page 6

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

Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0930
3. Check only one box below indicating how long Medicare can use this authorization to disclose
your personal health information (subject to applicable law—for example, your State may limit
how long Medicare may give out your personal health information):
Disclose my personal health information indefinitely
Disclose my personal health information for a specified period only
beginning:
(mm/dd/yyyy) and ending:
(mm/dd/yyyy)
4. Fill in the name and address of the person or organization to whom you want Medicare to
disclose your personal health information. Please provide the specific name of the person for
any organization you list below. If you would like to authorize any additional individuals or
organizations, please add those to the back of this form.
Name
Address
Name
Address
Form CMS-10106 (Rev 07/15)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Va Form 10-0485 - Request For And Authorization To Release Protected Health Information To Nationwide Health Information Network Va Form 10-0485 - Request For And Authorization To Release Protected Health Information To Nationwide Health Information Network Legal
Authorization For Disclosure Of Health Information Form - Minnesota Student Health Services Authorization For Disclosure Of Health Information Form - Minnesota Student Health Services Medical
Authorization For Disclosure Of Health Information Authorization For Disclosure Of Health Information Legal
Authorization For Disclosure Of Health Information Authorization For Disclosure Of Health Information Medical
Authorization For Disclosure Of Health Information Authorization For Disclosure Of Health Information Legal
Form Mr-465-8 Nis-authorization For Disclosure Of Health Information Form Form Mr-465-8 Nis-authorization For Disclosure Of Health Information Form Business
Form 4361 As - Authorization To Disclose Protected Health Information Form 4361 As - Authorization To Disclose Protected Health Information Business
Form 4361 Or - Authorization To Disclose Protected Health Information Form 4361 Or - Authorization To Disclose Protected Health Information Legal
Form 4361 Wa - Regence Authorization To Disclose Protected Health Information Form 4361 Wa - Regence Authorization To Disclose Protected Health Information Business
Authorization To Use & Disclose Health Information Form Authorization To Use & Disclose Health Information Form Business

Related Categories

Parent category: Medical
Download
Go
Page of 8