Medicare Form Summary
CMS-10106 is a standard disclosure form for Medicare. You’ll use this form to let Medicare know who can have access to your personal health information.
What you’ll need:
• The names and addresses of anyone to whom you wish to disclose your personal health information
Other important information:
• You can choose whether to disclose limited information.
• You can decide whether Medicare shares the information indefinitely or only for a specific period of time.