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Centers for Medicare & Medicaid Services

Fill out Form CMS-10106 online

Authorization to Disclose Personal Health Information Release Form

Form CMS-10106 gives 1-800-MEDICARE written permission to share your personal health information with a person or organization you name. By law, 1-800-MEDICARE needs this permission in writing before it can share your information with anyone other than you. The form can also be used to get information about a person with Medicare who has died, if you have the legal right to it.

Fill out Form CMS-10106Blank form from the CMS

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Edition
(03/2026)
Pages
3
Fillable fields
44
Checked against the CMS
November 8, 2026

GuruPDF is not affiliated with the Centers for Medicare & Medicaid Services. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses Form CMS-10106

  • People with Medicare who want 1-800-MEDICARE to be able to talk about their claims and health records with someone they choose
  • Personal representatives, such as a person with power of attorney, who sign for a person with Medicare
  • Executors and others with court papers who need information about a person with Medicare who has died

Before you start

  • The Medicare Number and date of birth of the person with Medicare
  • The mailing address, phone number and email address of the person with Medicare
  • The full name and mailing address of each person or organization that may get the information
  • Which information you want shared, and whether it should be shared indefinitely or only between a start date and an end date
  • If you sign as a personal representative: a copy of the paperwork that shows you can act for the person, like a Power of Attorney
  • If the person with Medicare has died: a copy of the legal documents that give you the right to the information

How to fill out Form CMS-10106

  1. Information about the person with Medicare

    Enter the first, middle and last name and any suffix, the Medicare Number, the date of birth (mm/dd/yyyy), the mailing address, the phone number and the email address of the person whose information will be shared.

  2. Who can get the information

    Under Person/Organization 1 and Person/Organization 2, enter the full name and mailing address of each person or organization that 1-800-MEDICARE may share the information with. To name more than two, list their names and addresses on the back of the form.

  3. Choose the information to share

    Check only one box: Any information or Limited information. If you check Limited information, check each type you want shared: Medicare eligibility, Medicare claims, Health & drug plan enrollment, Premium payments, or Other. If you check Other, write in what else may be shared, for example payment information.

  4. For New York residents only

    New York State law protects information about alcohol and drug abuse, mental health treatment and HIV. If you live in New York, check Yes or No to say whether 1-800-MEDICARE may share that information.

  5. How long the authorization lasts

    Check one box: share the information indefinitely, or share it only for a set period. If you choose a set period, enter the start date and end date. The form notes that your state may have different limits on how long Medicare can share your information.

  6. Reason for sharing

    Explain why you are giving 1-800-MEDICARE permission to share your information. The form says you can write "At my request."

  7. Signature and personal representative information

    Sign the form and enter the date signed (mm/dd/yyyy). If you are signing as a personal representative, check the box in the Personal Representative Information section, enter your name, mailing address, phone number and relationship to the person with Medicare, and attach a copy of the paperwork that shows you can act for the person.

After you fill it out

The form goes to 1-800-MEDICARE. The form says you can submit it online by logging in to your secure Medicare.gov account, or mail the completed and signed form to the 1-800-MEDICARE Written Authorization Dept. If you are asking for information about a person with Medicare who has died, include a copy of the legal documents that give you the right to it. Use the mailing address printed on the current form.

Signing: The person with Medicare, or a personal representative acting for them, signs and dates the Signature section; the form says to mail a completed and signed form or to submit it online through a secure Medicare.gov account. The form does not say whether a typed signature is accepted on a paper copy, so follow the instructions on the form and on the official CMS page.

Watch out for

  • Do not mail the completed form to the CMS address in the Paperwork Reduction Act statement. The form says a form sent there cannot be processed and your request will be significantly delayed.
  • A personal representative must attach a copy of the paperwork that shows they can act for the person with Medicare, like a Power of Attorney.
  • For a person who has died, include a copy of the legal documents that give you the right to the information, such as Executor papers or court documents with a court stamp and a judge's signature.
  • By signing, you confirm that you understand the people or organizations you name may share your information, and that it may then no longer be protected by law.

Questions about Form CMS-10106

Can I name more than two people or organizations?

Yes. The form has space for two. To share with more, list each name and address on the back of the form.

How do I cancel the authorization?

You can change or cancel (revoke) it at any time by writing to the same 1-800-MEDICARE Written Authorization Dept. address. Your letter stops future sharing, but it does not undo information already released under your original permission.

Can I use this form for someone who has died?

Yes, if you have the legal right to the information, for example as an Executor or through court documents. Include a copy of the legal documentation with the form.

How long does the permission last?

You choose. You can allow sharing indefinitely or only between a start date and an end date. The form notes that your state may have different limits.

Who can I call for help with the form?

The form says to call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Official information

Page text last reviewed November 7, 2026.

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