The person with Medicare
Name, Medicare Number, date of birth, mailing address, phone number and email address.
CMS-10106
1-800-Medicare Authorization to Disclosure Personal Health Information
- Agency
- CMS
- Revision
- 03/2026
- Fillable fields
- 44
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10106: Authorization to Disclose Personal Health Information
Form CMS-10106 is the Centers for Medicare & Medicaid Services release form that gives 1-800-MEDICARE permission to share a person's personal health information with someone other than that person. The form says that, by law, 1-800-MEDICARE needs this permission in writing before it can share any information with someone else.
The form can also be used to get information about a person with Medicare who has died, when the requester has a legal right to it, for example as an executor or with court documents that give that right. The person with Medicare signs it, or a personal representative signs for them.
The form says it can be submitted online through a secure Medicare.gov account or mailed to the address printed on it. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10106
Who can get the information
The full name and mailing address of up to two people or organizations. The form says to list any more on the back of the form.
What information to share
One box for any information or limited information. Limited information offers Medicare eligibility, Medicare claims, health and drug plan enrollment, premium payments and other types you write in.
New York residents only
A yes or no choice on sharing information about alcohol and drug abuse, mental health treatment, or HIV, which the New York State Public Health Law protects.
How long and why
Share indefinitely or only between a start date and an end date, and a reason for the permission. The form says you can write "At my request." and notes that your state may have different limits.
Signature and representative
The signature and date, and a personal representative section with name, mailing address, phone number and relationship to the person with Medicare.
How to submit Form CMS-10106
- 1
Fill in the person's details
Enter the name, Medicare Number and date of birth of the person with Medicare, with their mailing address, phone number and email.
- 2
Name who gets the information
Give each person's or organization's full name and mailing address. More than two go on the back of the form.
- 3
Choose what and for how long
Check any or limited information, the types to share, and whether the permission is indefinite or for set dates.
- 4
Sign and date it
The form says signing authorizes 1-800-MEDICARE to share the listed information, and that information shared with the people named may no longer be protected by law.
- 5
Attach legal papers if needed
A personal representative attaches papers like a Power of Attorney. A request about a person who has died includes a copy of the legal documentation, such as executor papers or court documents with a court stamp and a judge's signature.
- 6
Submit online or by mail
The form says to log in to a secure Medicare.gov account to submit it online for faster service, or to mail the completed, signed form to the address printed on it.
Why fill Form CMS-10106 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and how to cancel
Online
The form says to log in to your secure Medicare.gov account to submit it online for faster service. The CMS page for the form points to Medicare Online Forms under its related links for filling out and submitting it online.
By mail
Mail the completed and signed form to 1-800-MEDICARE Written Authorization Dept., PO Box 1270, Lawrence, KS 66044, as printed on the form.
Not the Baltimore address
The CMS address in the Paperwork Reduction Act notice is for comments on the form. The form says a completed form mailed there can't be processed and the request will be significantly delayed.
Canceling the permission
The form says you can change or cancel (revoke) the authorization at any time by writing to the mailing address above. Information already released based on the original permission is not affected.
Help with the form
Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. The form says Medicare information is also available in accessible formats like large print, braille or audio.
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Who uses Form CMS-10106?
The form is completed for the person with Medicare whose information 1-800-MEDICARE would share.
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Questions about Form CMS-10106
Why does 1-800-MEDICARE need Form CMS-10106?
The form says that, by law, 1-800-MEDICARE needs written permission before it can share any information with someone other than the person with Medicare. This form is that written permission.
How many people can I name on Form CMS-10106?
The form has room for two people or organizations. To share with more, it says to list their names and addresses on the back of the form.
How long does the permission last?
You choose on the form: indefinitely, or only between a start date and an end date. The form notes that your state may have different limits on how long Medicare can share your personal health information.
Can I cancel the authorization later?
Yes. The form says you can change or cancel it at any time by writing to the 1-800-MEDICARE Written Authorization Dept. address. Information already released based on the original permission stays released.
Can I use Form CMS-10106 for someone who has died?
The form says yes, if you have a legal right to the information, for example as an executor or with court documents. It asks for a copy of that legal documentation, such as a Letter of Testamentary or Administration with a court stamp and a judge's signature.
Can I submit Form CMS-10106 online?
The form says that for faster service you can submit it online by logging in to your secure Medicare.gov account. Otherwise you mail the signed form to PO Box 1270, Lawrence, KS 66044.
What should I write as the reason?
The form asks why you are giving 1-800-MEDICARE permission to share your information and says you can write "At my request."