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This version of the form is not currently in use and is provided for reference only. Download this version of
Form CMS-10106
for the current year.
Form CMS-10106 1-800-medicare Authorization to Disclose Personal Health Information
What Is Form CMS-10106?
This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on June 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CMS-10106?
A: Form CMS-10106 is an authorization form to disclose personal health information.
Q: What is the purpose of Form CMS-10106?
A: The purpose of Form CMS-10106 is to allow individuals to authorize the disclosure of their personal health information to third parties.
Q: Who should use Form CMS-10106?
A: Anyone who wishes to authorize the disclosure of their personal health information to third parties should use Form CMS-10106.
Q: What information is required on Form CMS-10106?
A: Form CMS-10106 requires personal details, the purpose of disclosure, recipient information, and signature of the individual authorizing the disclosure.
Q: Is there a fee for submitting Form CMS-10106?
A: There is no fee for submitting Form CMS-10106.
Q: How long does it take to process Form CMS-10106?
A: The processing time for Form CMS-10106 may vary, but it usually takes a few weeks.
Q: Can I revoke the authorization given on Form CMS-10106?
A: Yes, you can revoke the authorization given on Form CMS-10106 at any time by submitting a written request.
Form Details:
- Released on June 1, 2018;
- The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form CMS-10106 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services.
Download Form CMS-10106 1-800-medicare Authorization to Disclose Personal Health Information
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