This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information. Show
Where to Return Your Completed Authorization Forms:After you complete and sign the authorization form, return it to the address below: Medicare CCO, Written Authorization Dept. For New York Medicare Beneficiaries ONLYThe 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.
Instructions for Completing Section 2C of the Authorization Form:Please select one of the following options.
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 Encl. Information to Help You Fill Out the “1-800-MEDICARE Authorization to Disclose Personal Health Information” FormBy 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 instruction 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.
You should make a copy of your signed authorization for your records before mailing it to Medicare. 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. Form CMS-10106 (Rev 03/19) Department of Health and Human Services Form Approved 1-800-MEDICARE Authorization to Disclose Personal Health InformationUse this form if you want 1-800-MEDICARE to give your personal health information to someone other than you. 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. 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.
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. 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. Form CMS-10106 (Rev 03/19 What is authorization for disclosure of health information?An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
What is an authorization to release information form?Authorization to Release Information
This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows EBD (ARBenefits) to release your protected health information to a person or organization that you choose.
What is HIPAA compliant authorization?HIPAA Authorization Defined
A HIPAA authorization is consent obtained from an individual that permits a covered entity or business associate to use or disclose that individual's protected health information to someone else for a purpose that would otherwise not be permitted by the HIPAA Privacy Rule.
What is a PHI consent form?HIPAA Authorization for Research
A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.
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