Get Dhhs Cms-10106 2015

The DHHS CMS-10106 form is essential for allowing Medicare to share your personal health information with designated individuals. This guide will provide clear, step-by-step instructions for completing this form online, ensuring a smooth and efficient process.

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

1. Click the ‘Get Form’ button to access the DHHS CMS-10106 document in an online format.
2. Begin by printing the name of the person with Medicare in the designated field. Next, accurately enter the Medicare number as it appears on the Medicare card, followed by the person’s date of birth in the mm/dd/yyyy format.
3. In section 2, indicate how much personal health information Medicare may disclose. Check the appropriate box in question 2A, then complete question 2B if selecting 'Limited Information'. Specify the types of information you wish to disclose, such as Medicare eligibility or claims information.
4. If you reside in New York, complete section 2C by selecting whether to include or exclude information about alcohol, drug abuse, mental health treatment, and HIV.
5. Next, determine the duration for which the authorization is valid in section 3. Select whether to disclose information indefinitely or for a specified time frame, and fill in the necessary dates.
6. Enter the names and addresses of the individuals or organizations who will receive the disclosed information in section 4. Ensure to provide specific names for any listed organizations.
7. In section 5, the person with Medicare or their personal representative must sign and date the form. If a representative completes the form, they should check the box and include their contact information along with documentation that confirms their authority to act on behalf of the person with Medicare.
8. Finally, send the completed and signed form to the address provided on the authorization form. Make sure to keep a copy of the signed authorization for your records.

Complete your DHHS CMS-10106 form online today to ensure your personal health information is properly shared with your designated individuals.