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.