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How to Use Your Medicare Authorization Form

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How to Use Your Medicare Authorization Form

A Medicare Authorization to Disclose Personal Health Information keeps your health records secure.

Shannon Lorenzen

Updated: July 24, 2019    Published: July 22, 2019

doctor showing gray hair patient screen | Medicare PHI Release Form

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Your medical history is private. Any health information collected and recorded by a healthcare professional is considered to be protected health information (PHI).  This includes demographic information (age, ethnicity, and contact information) as well as any diagnoses, treatment, medical test results, or prescribed medications that may result from a visit to your healthcare provider.

By law, PHI can only be shared with your explicit permission. Medicare must have your written permission to give out any of this protected medical information. The Medicare Authorization to Disclose Personal Health Information form — also known as form CMS-10106 — is a standard release-of-information form.

You’ll need to fill out a Medicare Authorization form to request that Medicare allow any person or organization other than yourself to have access to your medical records.

Why Would You Fill Out the Medicare Authorization to Disclose Personal Health Information Form? And Who Gets This Info?

Your personal health information is protected by the Health Insurance Portability and Accountability Act (HIPPA). This means that your health status and any care or treatment provided to you by a hospital or healthcare provider is confidential.

#Medicare will not give away your health information, unless you request for them to do so in writing. Click To Tweet

There are some circumstances in which you may want or need an outside party to have access to your health records. For example, when visiting a new doctor’s office for the first time; when a device salesperson needs to question your doctor about a bill to authorize payment; or you may need to provide proof that an injury wasn’t a pre-existing condition.

Typically, you’ll only need to fill out this form if you are asked to do so by an outside party — usually a medical provider or a law firm. The only people who will receive this information are the people or organization(s) you specifically list on the form.

It’s important to note that your decision to authorize or refuse the disclosure of your personal health information has no effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services you receive.

Medicare Authorization to Disclose PHI main form

Do You Have to Release All Your Personal Health Information?

The depth of information that you would like to disclose is completely up to you. The Medicare Authorization to Disclose Personal Health Information gives you options to share limited information if you prefer. Medicare will only release the information that you specifically authorize.

You can also decide whether Medicare shares this information indefinitely or for a specific period of time. If you choose to only share your information for a specified period, you’ll need to include a start and end date in the appropriate section on the form.

Who Should Fill This Form Out?

Ideally, since this is a legal document, you should fill out your own form. However, Medicare does allow for an authorized representative to fill out this form if there are extenuating circumstances.

If you are completing this form for a deceased beneficiary or as a representative for someone who is unable to make the request for themselves, you will need to provide further legal documentation that indicates that you are legally able to request this information. Acceptable forms include:

  • Executor papers
  • Court documents with a court stamp and judge’s signature indicating you are next of kin or a personal representative
  • Proof of Power of Attorney

You will need to provide a copy of these forms with the completed Medicare Authorization form.

What Do You Need to Complete The Medicare Authorization Form?

Medicare will need you to provide some basic information about yourself, as well as the people or organizations you wish to disclose your personal health information to. You’ll need to provide:

  • Your name, date of birth, Medicare number, and telephone number.
  • The name(s) and address(es) of the people or organization(s) you wish to have your personal health information. If you are providing information to an organization, you’ll need to provide the name of a contact person who is designated to receive your health information.
  • A reason for the disclosure of your medical information.
    • You can choose “at my request” if you don’t care to provide details.
  • If you are a personal representative, you’ll also need to provide your personal phone number, your personal address, your relationship to the beneficiary, and attach the appropriate legal documents.

Once the forms are filled out, you must submit them to Medicare by mail to the following address:

Medicare CCO, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044

This address is accurate as of July 2019. Check the end of your form to confirm the appropriate address.

What if You Change Your Mind About Sharing Health Information?

You have the right to take back your authorization at any point. Medicare will comply as long as it hasn’t already carried out your original request to share your medical information.

If you would like to revoke your previously submitted authorization, you must send a written request to the same address listed above.

There’s so much more to Medicare. If you want other information about your coverage, there are plenty of ways you can get assistance. You can compare plans, or call a licensed independent agent via at any time. They’re able to help you find answers to your Medicare questions.

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