OMB no. 0938-0930 Medicare Authorization to Disclose Personal Health Information Use this form to ask Medicare to give out (disclose) your personal health information to the individual or organization you choose. Section 1 ___________________________ Print Person with Medicare's First & Last Name _______________________ Medicare Number ______________________ Date of Birth (mm/dd/yyyy) Print person with Medicare's first and last name as shown on the Medicare card. Section 2 Medicare will only disclose the personal health information you want disclosed. Check () box 2A or 2B. Do not check both boxes. New York residents must also complete Box 2C. 2A - I want Medicare to release any information. OR For limited disclosure of information, check the box 2B below and select the appropriate information to tell Medicare the specific personal health information you want disclosed: 2B ­ I want Medicare to ONLY release the limited information checked below: Check all that apply. Information 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 printed on the line below. If this circle is checked, you must include a description of information to be released or the request cannot be processed.) ____________________________________________________________ o o o o o ____________________________________________________________ Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com OMB no. 0938-0930 Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com OMB no. 0938-0930 2C - NY Residents Only, this section must be completed.) Please select one of the following options: (Please check only one box.) a) Include all information. This includes information about alcohol and drug abuse, mental health treatment, and HIV. OR b) Exclude information about alcohol and drug abuse, mental health treatment, and HIV. Section 3 How long should Medicare release the information to the authorized individuals or organization? (This is subject to applicable law ­ for example, your state may limit how long Medicare may give out your personal health information.) Check only one box. a) Disclose my personal health information indefinitely. OR b) Disclose my personal health information for a specified period: ______________________ ______________________ Beginning date (mm/dd/yyyy) Ending date (mm/dd/yyyy) (If selecting b, you must include a stop and start date or the request cannot be processed.) Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com OMB no. 0938-0930 Section 4 Fill in the name and address of the person(s) or organization(s) to whom you want Medicare to disclose your personal health information in the section(s) below. If you need to list additional names, you may attach a sheet of paper to this form. (Include your name and Medicare number on the additional sheet.) Please provide the specific name of the person(s) for any organization you listed below: Name: Address: (required) Name: Address: (required) Name: Address: (required) Section 5 I authorize Medicare to disclose my personal health information listed in section 2 to the person(s) and/or organization(s) I have named on this form. I understand that my personal health information may be re-disclosed by the person(s) and/or organization(s) and may no longer be protected by law. ______________________________ Signature ( )_____________ Telephone Number ______________________ Today's Date (mm/dd/yyyy) Print the person with Medicare's address (street address, city, state and ZIP Code): ___________________________________________________________________________ ___________________________________________________________________________ If the person with Medicare signs section 5 above, do not complete section 6. Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com OMB no. 0938-0930 Section 6 - For Personal Representative Only Important information: This section should only be completed if someone other than the person with Medicare signs in section 5. Check here if you are signing as a personal representative of the person with Medicare and complete the information below. Please attach the appropriate legal documentation (for example, Power of Attorney or Executorship). See the instructions on submitting the appropriate legal documents. Signature: __________________________________________________________ Print the personal representative's address (street address, city, state and ZIP Code): _________________________________________________________________________ _________________________________________________________________________ Personal representative's telephone number: ( )_______________________ You should make a copy of your signed authorization for your records before mailing it to Medicare. Send the completed, signed authorization to: Medicare BCC, Written Authorization Dept.P.O. 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 your authorization, send a written request to the address shown above. Your authorization of refusal to authorize disclosure of your personal health information will have no effect on your enrollment, eligibility or benefits, or the amount Medicare pays for the health services you receive. Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com OMB no. 0938-0930 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 average15 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. Standard form 10106 (March 2011) American LegalNet, Inc. www.FormsWorkFlow.com