DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0930

AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION RELEASE FORM

WHO CAN USE THIS FORM? WHERE TO SEND YOUR COMPLETED

People with Medicare who want 1-800-MEDICARE to be AUTHORIZATION FORM
able to share their personal information with people After you complete and sign the authorization form,
they choose. return it to:
NOTE: By law, you must give 1-800-MEDICARE 1-800-MEDICARE
permission in writing before 1-800-MEDICARE can Written Authorization Dept.
share any information with someone other than you.
Find the full list of how 1-800-MEDICARE uses your PO Box 1270
information in the privacy notice within the Medicare Lawrence, KS 66044
& You handbook.
For faster service, you may submit this form online by
logging in to your secure online Medicare.gov account.
WHEN DO YOU USE THIS FORM?
• To add someone that 1-800-MEDICARE can share FOR NEW YORK RESIDENTS WITH MEDICARE
information with. ONLY
• To change or remove someone that The New York State Public Health Law protects the
1-800-MEDICARE can share information with. privacy of information related to alcohol and drug
• To get information for someone who is deceased abuse, mental health treatment, and HIV. Because
(if you legally have the right to that information of this law, New York Residents must follow specifc
because you’re an Executor or have court documents instructions for completing section 2. Instructions are
giving you rights to that information.) located at the end of this form.

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.

Form CMS-10106 (05/23)

Instructions
DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0930

AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION RELEASE FORM

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

2. Choose the information you want 1-800-MEDICARE to share.

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)

Form CMS-10106 (05/23)

DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES 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 Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES 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 Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0930

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 • Section 2B: Check 1 or more of the boxes
about the person with Medicare who’s and include any other specific information
authorizing the release of their personal health you’re giving us permission to share in the
information: space provided. For example, you could
write “payment information”.
• Name
• Medicare number (enter the number exactly • Section 2C: Check one of the boxes to tell
as it appears on the red, white, and blue us how much of your personal information
Medicare card) we’re allowed to share:
• Date of birth o If you give us permission to share all
• Address your information, check the box: “All
information, including information about
2. In section 2A, check a box to tell us how much alcohol and drug abuse, mental health
personal health information we’re allowed to treatment, and HIV”.
share. You can choose to let us share all of your o If you don’t give us permission to share
personal health information, or only limited information about alcohol and drug
information. If you decide you only want us to abuse, mental health treatment, and
share limited information, check 1 or more of HIV, check the box: “Don’t include
the boxes in section 2B to indicate which types information about alcohol and drug
of information you’re giving us permission to abuse, mental health treatment, and
share (for example, Medicare eligibility). HIV”.

IMPORTANT: Special instructions for New York 3. In this section, check a box to tell us if you give
residents us permission to share your personal health
information indefinitely, or only for a specific
The New York State Public Health Law period of time. If you only want us to share
protects the privacy of information related your information for a certain period of time,
to alcohol and drug abuse, mental health enter the start and stop dates for sharing your
treatment, and HIV. Because of this law, New information.
York Residents must follow these instructions
for completing section 2: 4. Explain why you’re giving us permission to share
your personal health information.
• Section 2A: Check the box for Limited
Information, even if you want to let us
share any and all of your personal health
information.

Form CMS-10106 (05/23)

Instructions
DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0930

5. Enter the name of each person or organization 7. Mail your completed, signed authorization form.
that can get your personal health information. Make a copy of your signed authorization form
You may list more than 1 person or for your records before you mail it.
organization.
If you include an organization, you must 1-800-MEDICARE
also identify at least 1 person within that Written Authorization Dept.
organization who can get your personal PO Box 1270
health information. Lawrence, KS 66044

6. Sign and date the form, then enter your 8. If you change your mind later and no longer
telephone number. want us to share your personal health
information, write to the address shown in
If you’re completing the form for someone section 7 and tell us. Your letter will cancel your
with Medicare: authorization form, and we’ll no longer share
your personal health information (except for any
• Sign and date the form, then enter their information we already released based on your
telephone number. original permission).
• Check the box to indicate that you’re signing
the form as a personal representative. If you have any questions or need help with
this form, call us at 1-800-MEDICARE
• Enter your address, phone number, and (1-800-633-4227). TTY users can call
relationship to the person with Medicare. 1-877-486-2048.
• Attach a copy of the paperwork that shows
you can act for the person (for example,
Power of Attorney).

You have the right to get Medicare information in an accessible format, like large print, braille, or audio.
You also have the right to file 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
Officer, 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.

Form CMS-10106 (05/23)

Instructions