What is Medicare Authorization Form And How to Use it? Your medical history is totally confidential under the law. Any health information that a healthcare provider collects and records is considered federally protected health information (PHI). This includes demographic data, age, ethnicity, and contact information, as well as any diagnoses, treatments, medical test results, or prescription drugs that may arise as a result of a visit to your healthcare practitioner. Protected health information (PHI) can only be released with your explicit authorization, according to the law.
To share any of this protected medical information with anyone, including physicians and others, Medicare needs your written authorization. If you fill out the Medicare Authorization to Disclose Personal Health Information form, commonly known as CMS-10106, you might choose to share your medical records. By completing the Medicare Authorization form, you formally request that Medicare grant access to your medical records to anybody or any entity other than yourself.
It's entirely up to you how much information you want to provide. If you wish, the Medicare Authorization to Disclose Personal Health Information gives you the option of sharing just limited information. Only the information that you specifically approve will be released by Medicare. You can also choose whether Medicare distributes this information permanently or only for a limited time. If you only want to share your information for a certain amount of time, make sure to provide a start and end date in the corresponding part of the form.
Because this is a legal document, you should fill it out yourself if possible. If there are extenuating circumstances, Medicare will enable an authorized representative to fill out this form. If you're filling out this form on behalf of a deceased beneficiary or a representative for someone who is unable to make this request for themselves, you'll need to supply additional legal papers proving that you have the legal authority to do so.
The following are examples of acceptable forms:
Court documents with a judge's signature and a court seal showing that you are a relative or personal representative
Power of Attorney
You must provide a copy of these documents together with the completed Medicare Authorization form.
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The Health Insurance Portability and Accountability Act (HIPPA) protects your personal health information. This means that your health information, as well as any care or treatment you receive from a hospital or healthcare practitioner, is kept private.
You may want or need an outside entity to have access to your medical records in certain circumstances. For example, you may need to provide proof that an injury wasn't caused by a pre-existing condition when visiting a new doctor for the first time; a device salesperson may need more information to authorize a payment, or you may need to provide proof that an injury wasn't caused by a pre-existing condition.
You normally fill out this form after being invited to do so by a third party, such as a medical practitioner or a law company. The only persons or organizations that will receive this information are those you specify on the form. It's important to remember that whether you authorize or decline the release of your personal health information has no bearing on your membership, benefits eligibility, or the amount Medicare pays for the health services you get.
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You'll need to give Medicare some basic information about yourself, as well as the people or organizations to whom you want to share your personal health information. You'll need to submit the following information:
The name(s) and address(es) of the person(s) or organization(s) to whom you want your personal health information to be disclosed. If you're giving information to an organization, you'll need to supply the name of a contact person who has been assigned to receive your medical records.
If you are a personal representative, you must additionally include your personal phone number, address, and relationship to the beneficiary, as well as attach the necessary legal documents.
An explanation for why your medical information was disclosed. If you don't want to disclose details, select "at my request."
Your full name, date of birth, Medicare number, and contact information.
Once you've completed the paperwork, you must mail them to Medicare at the following address: Written Authorization Department, Medicare CCO, PO Box 1270 Lawrence, KS 66044.
Check the address at the bottom of your form to make sure it's correct.
You have the right to revoke your permission at any time. Medicare will comply if it hasn't already done so in response to your request to provide your medical information. You must send a formal request to the same address indicated above if you want to revoke your previously filed authorization.
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