Form CMS-10106 (05/23)
Instructions
AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION RELEASE FORM
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
WHO CAN USE THIS FORM?
People with Medicare who want 1-800-MEDICARE to be
able to share their personal information with people
they choose.
NOTE: By law, you must give 1-800-MEDICARE
permission in writing before 1-800-MEDICARE can
share any information with someone other than you.
Find the full list of how 1-800-MEDICARE uses your
information in the privacy notice within the Medicare
& You handbook.
WHEN DO YOU USE THIS FORM?
• To add someone that 1-800-MEDICARE can share
information with.
• To change or remove someone that
1-800-MEDICARE can share information with.
• To get information for someone who is deceased
(if you legally have the right to that information
because you’re an Executor or have court documents
giving you rights to that information.)
NOTE: If you change or remove someone,
1-800-MEDICARE can only apply that change to new
requests. Medicare can’t take back items we’ve already
shared with others you approved.
WHERE TO SEND YOUR COMPLETED
AUTHORIZATION FORM
After you complete and sign the authorization form,
return it to:
1-800-MEDICARE
Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For faster service, you may submit this form online by
logging in to your secure online Medicare.gov account.
FOR NEW YORK RESIDENTS WITH MEDICARE
ONLY
The New York State Public Health Law protects the
privacy of information related to alcohol and drug
abuse, mental health treatment, and HIV. Because
of this law, New York Residents must follow specific
instructions for completing section 2. Instructions are
located at the end of this form.
Form CMS-10106 (05/23)
AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION RELEASE FORM
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
Use this form to tell 1-800-MEDICARE who can access your personal health information. Whether you choose to
share your personal health information or not has no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for your health services.
INFORMATION ABOUT THE PERSON WITH MEDICARE
Use this form if you want 1-800-MEDICARE to give your personal health information to someone other than you.
1. Name (First, Middle, Last, Suffix)
Medicare Identification Number Date of Birth (mm/dd/yyyy)
Street Address
City State Zip code
2A: Check only one box.
□ Limited Information (go to question 2B)
□ Any Information (go to question 3)
2B: What kind of “limited information” do you want us to share? (Check all that apply)
I want to share limited personal health information about my:
□ Medicare eligibility
□ Medicare claims
□ Plan enrollment (e.g. drug or MA Plan)
□ Premium payments
□ Other (Write any other information you want shared below. For example, payment information)
2.
Choose the information you want 1-800-MEDICARE to share.
Form CMS-10106 (05/23)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
2C: FOR NEW YORK RESIDENTS ONLY
Please select one of the following options. If you’re unsure, review the instructions at the end of this
form.
□ Include all information. This includes information about alcohol and drug abuse, mental health
treatment, and HIV.
□ Don’t include information about alcohol and drug abuse, mental health treatment, and HIV.
3. How long can 1-800-MEDICARE use this authorization to share your personal health information? Check only
one box. (Subject to applicable law—for example, your State may limit how long Medicare may give out your
personal health information):
□ Share my personal health information indefinitely.
□ Share my personal health information for a specific period of time:
Beginning: ____________________ (mm/dd/yyyy) and Ending: ____________________ (mm/dd/yyyy)
4. Explain why you’re giving 1-800-MEDICARE permission to share your information (You may write
“At my request”):
5. Enter the name of each person or organization that can get your personal health information from
1-800-MEDICARE. If you want to share your information with more than 2 people or organizations, list them on
the back of this form. Be sure to include their name and address.
Person/Organization 1
Full Name
Street Address
City State Zip code
Person/Organization 2
Full Name
Street Address
City State Zip code
Form CMS-10106 (05/23)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
6. By signing this form, I authorize 1-800-MEDICARE to share my personal health information listed above to the
person(s) or organization(s) I named on this form. I understand that my personal health information may be
shared by the person(s) or organization(s) and may no longer be protected by law.
Signature Telephone Number Date (mm/dd/yyyy)
□ Check here if you are signing as a personal representative and complete the form below.
Be sure to attach the appropriate documentation (like a Power of Attorney) if someone other than the
person with Medicare signed above.
Personal Representative's Information
Full Name
Street Address
City State Zip code
Telephone Number Relationship to the
person with Medicare
7. Send the completed, signed authorization form to:
1-800-MEDICARE
Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
8. Important: You have the right to cancel (“revoke”) your authorization at any time. To cancel your
authorization, send a written request to the address above. After we process the request, we’ll no longer
share your personal health information (except for any information we already released based on your
original permission).
Form CMS-10106 (05/23)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
Instructions
STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS FORM
By law, Medicare must have your written permission (an “authorization”) to use or give out your
personal health information for any reason that isn’t described in the privacy notice in the Medicare &
You handbook. You may take back (“revoke”) your written permission at any time, except if Medicare
has already released information based on your permission.
If you want someone to be able to call 1-800-MEDICARE on your behalf or you want us to share your
personal health information with someone other than you, you need to let Medicare know in writing.
If you’re requesting personal health information for a deceased person who had Medicare, please
include a copy of the legal documentation that gives you the authority to request this 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, explain
your relationship to the person with Medicare.
Follow these instructions to complete your form. Be sure to complete all sections so we can process your
form on time.
1. In section 1, enter the following information
about the person with Medicare who’s
authorizing the release of their personal health
information:
•
Name
•
Medicare number (enter the number exactly
as it appears on the red, white, and blue
Medicare card)
•
Date of birth
•
Address
2. In section 2A, check a box to tell us how much
personal health information we’re allowed to
share. You can choose to let us share all of your
personal health information, or only limited
information. If you decide you only want us to
share limited information, check 1 or more of
the boxes in section 2B to indicate which types
of information you’re giving us permission to
share (for example, Medicare eligibility).
IMPORTANT: Special instructions for New York
residents
The New York State Public Health Law
protects the privacy of information related
to alcohol and drug abuse, mental health
treatment, and HIV. Because of this law, New
York Residents must follow these instructions
for completing section 2:
•
Section 2A: Check the box for Limited
Information, even if you want to let us
share
any and all of your personal health
information.
•
Section 2B:
Check 1 or more of the boxes
and include any other specific information
you’re giving us permission to share in the
space provided. For example, you could
write “payment information”.
•
Section 2C:
Check one of the boxes to tell
us how much of your personal information
we’re allowed to share:
o
If you give us permission to share all
your information, check the box: “All
information, including information about
alcohol and drug abuse, mental health
treatment, and HIV”.
o If you don’t give us permission to share
in
formation about alcohol and drug
abuse, mental health treatment, and
HIV, check the box: “Don’t include
information about alcohol
and drug
abuse, mental health treatment, and
HIV”.
3. In this section, check a box to tell us if you give
us permission to share your personal health
information indefinitely, or only for a specific
period of time. If you only want us to share
your information for a certain period of time,
enter the start and stop dates for sharing your
information.
4. Explain why you’re giving us permission to share
your personal health information.
Instructions
Form CMS-10106 (05/23)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0930
5. Enter the name of each person or organization
that can get your personal health information.
You may list more than 1 person or
organization.
If you include an organization, you must
also identify at least 1 person within that
organization who can get your personal
health information.
6. Sign and date the form, then enter your
telephone number.
If you’re completing the form for someone
with Medicare:
•
Sign and date the form, then enter their
telephone number.
•
Check the box to indicate that you’re signing
the form as a personal representative.
•
Enter your address, phone number, and
relationship to the person with Medicare.
•
Attach a copy of the paperwork that shows
you can act for the person (for example,
Power of Attorney).
7. Mail your completed, signed authorization form.
Make a copy of your signed authorization form
for your records before you mail it.
1-800-MEDICARE
Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
8. If you change your mind later and no longer
want us to share your personal health
information, write to the address shown in
section 7 and tell us. Your letter will cancel your
authorization form, and we’ll no longer share
your personal health information (except for any
information we already released based on your
original permission).
If you have any questions or need help with
this form, call us at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
You have the right to get Medicare information in an accessible format, like large print, braille, or audio.
You also have the right to le a complaint if you feel you’ve been discriminated against. Visit
Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227) for
more information. TTY users can call 1-877-486-2048.
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
Ofcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. DO NOT MAIL YOUR COMPLETED FORM TO THIS
ADDRESS. If you do, we won’t be able to process your form, and your request to release your personal health
information will be significantly delayed.
