Printable blank Medicare Authorization to Disclose Personal Health Information

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1. What is a Medical Authorization to Disclose Personal Health Information?

The fillable Medical Authorization to Disclose Personal Health Information (Form CMS 10106) is used for reporting Medicare about the person(s) you have granted access to your private health information. The form doesn’t require any attachments unless your health care provider requests them.

2. What I need the Medical Authorization to Disclose Personal Health Information for?

  • You have to file this form in order to inform Medicare about the person(s) you want to share your medical information with as well as the reason for that and the information that you want to share.

You can either download Medical Authorization to Disclose Personal Health Information from PDFLiner or use our online PDF editor to complete the form without quitting the website. The direct print feature is also provided.

3. How to fill out Medical Authorization to Disclose Personal Health Information?

This form’s blank includes 8 pages, on which you have to:

  • Read the full instruction on pages 1-4;
  • Enter your name, birth date, and valid Medicare number;
  • Report if you want to share limited information or any information about your health condition and choose the area of the disclosure;
  • If you’re a NY resident, you can either include or exclude the information about alcohol/drug abuse, HIV, and mental health treatment; 
  • Indicate the expiry date of the disclosure;
  • Name persons or organizations that can use the disclosure;
  • Consent that you are agreeing to share the selected pieces of information;
  • Appoint a personal representative;
  • Send the form to Medicare CCO.

4. Organizations that work with Medical Authorization to Disclose Personal Health Information:

  • Department of Health and Human Services;
  • Centers for Medicare and Medicaid Services.

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