Get Dhhs Cms-10106 2019-2026

The DHHS CMS-10106 form is essential for allowing Medicare to share your personal health information with designated individuals. This guide will help you navigate each step to complete the form accurately and effectively.

Follow the steps to successfully complete the DHHS CMS-10106 online.

1. Press the ‘Get Form’ button to access the DHHS CMS-10106 online form in the editor.
2. Begin by entering the name of the person with Medicare in the designated field.
3. Input the Medicare number as shown on the Medicare card, ensuring accuracy.
4. Provide the birth date of the person with Medicare formatted as month, day, and year (mm/dd/yyyy).
5. In section 2A, select one box to indicate whether you want limited information or any information disclosed.
6. If limited information is selected, fill out section 2B by checking all applicable boxes that detail what information can be disclosed.
7. New York residents must complete section 2C, choosing to either include or exclude sensitive information.
8. In section 3, indicate how long you wish for the authorization to remain valid: indefinitely or for a specified time period, filling in dates if necessary.
9. Provide a reason for the disclosure in section 4, or simply write 'at my request'.
10. List the names and addresses of the individuals or organizations you want Medicare to disclose information to in section 5.
11. Sign and date the form in section 6, and include contact information for the person with Medicare.
12. If applicable, indicate if you are signing as a personal representative and attach the necessary documentation.
13. Send your completed and signed form to the address provided, which is Medicare CCO, Written Authorization Dept., PO Box 1270, Lawrence, KS 66044.
14. Consider saving a copy of the completed form for your records before mailing.

Complete your DHHS CMS-10106 online today and ensure your health information is accessible to the right people.