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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 Form
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 December 1, 2021 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 the Authorization to Disclose Personal Health Information form.
Q: What is the purpose of Form CMS-10106?
A: The purpose of Form CMS-10106 is to authorize the disclosure of personal health information.
Q: How can I obtain Form CMS-10106?
A: You can obtain Form CMS-10106 by calling 1-800-MEDICARE.
Q: What is 1-800-MEDICARE?
A: 1-800-MEDICARE is the toll-free number to contact the Medicare program.
Q: Why do I need to complete Form CMS-10106?
A: You need to complete Form CMS-10106 in order to give permission for your personal health information to be shared with others.
Q: Can I use Form CMS-10106 for any other purpose?
A: No, Form CMS-10106 is specifically designed for the authorization to disclose personal health information.
Form Details:
- Released on December 1, 2021;
- 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 Form
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