1 800 Medicare Authorization To Disclosure Personal Health Information {CMS 10106}

CMS-10106 - 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. 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. www.FormsWorkflow.com