Form Cms-10106 - 1-800-Medicare Authorization To Disclosure Personal Health Information Page 8
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8Department of Health and Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0930
6. Send the completed, signed authorization to:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
Print Form
Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the
extent that Medicare has already acted based on your permission. If you would like to revoke
authorization, send a written request to the address noted above.
Your authorization or refusal to authorize disclosure of your personal health information will have no
effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services
you receive.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0930. The time required to complete this information collection is
estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
Form CMS-10106 (Rev 07/15)
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