Microsoft Word - CMS10106_OnlineAddition.docx

Medicare

Beneficiary Services:1-800-MEDICARE (1-800-633-4227)

TTY/ TDD:1-877-486-2048

This form is used to advise Medicare of the person or persons you have chosen to have access to your

personal health information.

For faster processing, you may complete your Authorization form online by logging into

www.MyMedicare.gov with valid credentials where Authorized Representatives can be added or

updated under ‘My Accounts’.

Where to Return Your Completed Authorization Forms:

After you complete and sign the authorization form, return it to the address below:

Medicare BCC, Written Authorization Dept.

PO Box 1270

Lawrence, KS 66044

For New York Medicare Beneficiaries ONLY

The New York State Public Health Law protects information that reasonably could identify someone as

having HIV symptoms or infection, and information regarding a person's contacts. Because of New

York's laws protecting the privacy of information related to alcohol and drug abuse, mental health

treatment, and

HIV, there are special instructions for how you, as a New York resident, should complete

this form.

• For question 2A, check the box for Limited Information, even if you want to authorize

Medicare

to release any and all of your personal health information.

• Then proceed to question 2B. You may also check any of the remaining boxes and include any

additional limitations in the space provided. For example, you could write "payment

information".

Instructions for Completing Section 2C of the Authorization Form:

Please select one of the following options.

• Option 1 To include all information, check the box: "All information, including

information about

alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest

of the form.

• Option 2 To exclude the information listed above, check the box "Exclude information about

alcohol and

drug abuse, mental health treatment, and HIV". Then proceed with the rest of the form.

If you have any questions or need additional assistance, please feel free to call us at 1-800-

MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Sincerely,

1-800-MEDICARE

Customer Service Representative

Encl.

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Form CMS-10106 (Rev 09/17)

Instructions

Information to Help You Fill Out the

“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form

By law, Medicare must have your written permission (an “authorization”) to use or give out

your

personal medical information for any purpose that isn't set out in the privacy notice

contained in the

Medicare & You handbook. You may take back (“revoke”) your written

permission at any time, except

if Medicare has already acted based on your permission.

If you want 1-800-MEDICARE to give your personal health information to someone other than

you,

you need to let Medicare know in writing.

If you are requesting personal health information for a deceased beneficiary, please include a

copy of

the legal documentation which indicates your authority to make a request for 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, please explain your

relationship to the beneficiary.

Please use this

step by step i

nstruction sheet when completing your “1-800-MEDICARE

Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections

of the

form to ensure timely processing.

1. Print the name of the person with Medicare.

Print the Medicare number exactly as it is shown on the red, white, and blue Medicare

card,

including any letters.

Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.

2. This section tells Medicare what personal health information to give out. Please check a

box in

2A to indicate how much information Medicare can disclose. If you only want

Medicare to

give out limited information (for example, Medicare eligibility), also check

the box(es) in 2B

that apply to the type of information you want Medicare to give out. Box 2C must be

completed by New York Residents.

3. This section tells Medicare when to start and/or when to stop giving out your personal

health

information. Check the box that applies and fill in dates, if necessary.

4. This section tells Medicare the reason for disclosure.

5. Medicare will give your personal health information to the person(s) or organization(s) you fill in

here. You may fill in more than one person or organization.

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Form CMS-10106 (Rev 09/17)

Instructions

If you designate an

organization, you must also identify one or more individuals in that

organization to whom Medicare may disclose your personal health information.

6. The person with Medicare or personal representative must sign their name, fill in the date,

and

provide the phone number and address of the person with Medicare.

If you are a personal representative of the person with Medicare, check the box, provide

your

address and phone number, and attach a copy of the paperwork that shows you can

act for that

person (for example, Power of Attorney).

7. Send your completed, signed authorization to Medicare at the address shown here on your

authorization form.

8. If you change your mind and don't want Medicare to give out your personal health

information,

write to the address shown under number six on the authorization form and

tell Medicare. Your

letter will revoke your authorization and Medicare will no longer

give out your personal health

information (except for the personal health information

Medicare has already given out based on

your permission).

You should make a copy of your signed authorization

for your records before mailing it to

Medicare.

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Form

CMS-10106 (Rev 09/17)

1-800-ME

DICARE 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

(First and last name of the person with Medicare)

Medicare Number

(Exactly as shown on the Medicare Card)

Date of Birth

(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:

Infor

mation 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.

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Form CMS-10106 (Rev 09/17)

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 reason for the disclosure (you may write "at my request"):

5.

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 ______________________________________________________________________

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Form CMS-10106 (Rev 09/17)

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. To revoke authorization,

send a written request to the address noted below. 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.

6.

I authorize 1-800-MEDICARE to disclose my personal health information listed above to

the person(s) or organization(s) I have named on this form. I understand that my

personal health information may be re-disclosed by the person(s) or organization(s) and

may no longer be protected by law.

Signature

Telephone Number

Date (mm/dd/yyyy)

Print the address of the person with Medicare (Street Address, City, State, and ZIP)

Check here if you are signing as a personal representative and complete below.

Please attach the appropriate documentation (for example, Power of Attorney).

This only

applies if someone other than the person with Medicare signed above.

Print the Personal Representative's Address (Street Address, City, State, and ZIP)

Telephone Number of Personal Representative:

Personal Representative's Relationship to the Beneficiary:

Department of Health and Human Services Form Approved

Centers for Medicare & Medicaid Services OMB No. 0938-0930

Fo

rm CMS-10106 (Rev 09/17)

7.

Se

nd the completed, signed authorization to:

Medicare BCC, Written Authorization Dept.

PO Box 1270

Lawrence, KS 66044

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.

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