Medicare Authorization Health Details

Authorization disclose health is a request form that authorizes healthcare providers to discuss an individual’s medical information with designated parties. The authorization disclose health form allows for the release of specific information about the patient’s care or treatment. This form should be completed by the patient and submitted to their healthcare provider. The authorization disclosure health form is an important document to have when seeking medical treatment. By completing this form, patients can ensure that their healthcare providers are able to communicate with designated individuals about their care and treatment.

You'll find information regarding the type of form you need to complete in the table. It will tell you the time it may need to complete authorization disclose health, exactly what parts you need to fill in, and so on.

QuestionAnswer
Form NameAuthorization Disclose Health
Form Length7 pages
Fillable?Yes
Fillable fields31
Avg. time to fill out8 min 1 sec
Other namesauthorization health medicare form, medicare authorization health, medicare authorization, medicare authorization form

Form Preview Example

This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information.

Where to Return Your Completed Authorization Forms:

After you complete and sign the authorization form, return it to the address below:

Medicare BCC, Written Authorization Dept.

PO Box 1270

Lawrence, KS 66044

For New York Medicare Beneficiaries ONLY

The New York State Public Health Law protects information that reasonably could identify someone as having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and HIV, there are special instructions for how you, as a New York resident, should complete this form.

For question 2A, check the box for Limited Information, even if you want to authorize Medicare to release any and all of your personal health information.

Then proceed to question 2B.

Instructions for Completing Section 2B of the Authorization Form:

Please select one of the following options.

Option 1 To include all information, in the space provided, write: "all information, including information about alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest of the form.

Option 2 To exclude the information listed above, write "Exclude information about alcohol and drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the remaining boxes and include any additional limitations in the space provided. For example, you could write "payment information". Then proceed with the rest of the form.

If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Sincerely,

1-800-MEDICARE

Customer Service Representative

Encl.

Information to Help You Fill Out the

“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form

By law, Medicare must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that isn't set out in the privacy notice contained in the Medicare & You handbook. You may take back (“revoke”) your written permission at any time, except if Medicare has already acted based on your permission.

If you want 1-800-MEDICARE to give your personal health information to someone other than you, you need to let Medicare know in writing.

If you are requesting personal health information for a deceased beneficiary, please include a copy of the legal documentation which indicates your authority to make a request for information. (For example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature, or personal representative papers with a court stamp and judge's signature.) Also, please explain your relationship to the beneficiary.

Please use this step by step instruction sheet when completing your 1-800-MEDICARE Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure timely processing.

1.Print the name of the person with Medicare.

Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 123456789A).

Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.

2.This section tells Medicare what personal health information to give out. Please check a box in 2a to indicate how much information Medicare can disclose. If you only want Medicare to give out limited information (for example, Medicare eligibility), also check the box(es) in 2b that apply to the type of information you want Medicare to give out.

3.This section tells Medicare when to start and/or when to stop giving out your personal health information. Check the box that applies and fill in dates, if necessary.

4.Medicare will give your personal health information to the person(s) or organization(s) you fill in here. You may fill in more than one person or organization. If you designate an organization, you must also identify one or more individuals in that organization to whom Medicare may disclose your personal health information.

5.The person with Medicare or personal representative must sign their name, fill in the date, and provide the phone number and address of the person with Medicare.

If you are a personal representative of the person with Medicare, check the box, provide your address and phone number, and attach a copy of the paperwork that shows you can act for that person (for example, Power of Attorney).

6.Send your completed, signed authorization to Medicare at the address shown here on your authorization form.

7.If you change your mind and don't want Medicare to give out your personal health information, write to the address shown under number six on the authorization form and tell Medicare. Your letter will revoke your authorization and Medicare will no longer give out your personal health information (except for the personal health information Medicare has already given out based on your permission).

You should make a copy of your signed authorization for your records before mailing it to Medicare.

and ending: (mm/dd/yyyy)

1-800-MEDICARE Authorization to Disclose Personal Health Information

Use this form if you want 1-800-MEDICARE to give your personal health information to someone other than you.

1. Print Name

Medicare Number

Date of Birth

(First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)

2.Medicare will only disclose the personal health information you want disclosed.

2A: Check only one box below to tell Medicare the specific personal health information you want disclosed:

Limited Information (go to question 2b)

Any Information (go to question 3)

2B: Complete only if you selected “limited information”. Check all that apply:

Information about your Medicare eligibility

Information about your Medicare claims

Information about plan enrollment (e.g. drug or MA Plan)

Information about premium payments

Other Specific Information (please write below; for example, payment information)

3.Check only one box below indicating how long Medicare can use this authorization to disclose your personal health information (subject to applicable law—for example, your State may limit how long Medicare may give out your personal health information):

Disclose my personal health information indefinitely

Disclose my personal health information for a specified period only beginning: (mm/dd/yyyy)

4.Fill in the name and address of the person(s) or organization(s) to whom you want Medicare to disclose your personal health information. Please provide the specific name of the person(s) for any organization you list below:

1. Name:

Address:

2.Name:

Address:

3.Name:

Address:

5.

I authorize 1-800-MEDICARE to disclose my personal health information listed above to the person(s) or organization(s) I have named on this form. I understand that my personal health information may be re-disclosed by the person(s) or organization(s) and may no longer be protected by law.

Signature

Telephone Number

Date (mm/dd/yyyy)

Print the address of the person with Medicare (Street Address, City, State, and ZIP)

Check here if you are signing as a personal representative and complete below. Please attach the appropriate documentation (for example, Power of Attorney). This only applies if someone other than the person with Medicare signed above.

Print the Personal Representative's Address (Street Address, City, State, and ZIP)

Telephone Number of Personal Representative:

Personal Representative's Relationship to the Beneficiary:

6.Send the completed, signed authorization to:

Medicare BCC, Written Authorization Dept.

PO Box 1270

Lawrence, KS 66044

7.Note:

You have the right to take back (“revoke”) your authorization at any time, in writing, except to the extent that Medicare has already acted based on your permission. If you would like to revoke your authorization, send a written request to the address shown above.

Your authorization or refusal to authorize disclosure of your personal health information will have no effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services you receive.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0930. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

How to Edit Authorization Disclose Health

We've used the efforts of the best computer programmers to create the PDF editor you may want to apply. The software will assist you to fill in the medicare authorization document easily and don’t waste your time. All you need to do is follow these straightforward tips.

Step 1: Choose the "Get Form Here" button.

Step 2: Once you've accessed your medicare authorization edit page, you'll discover all actions you may use with regards to your document within the top menu.

Please enter the next information to complete the medicare authorization PDF:

step 1 to filling in authorization disclose

The application will need you to submit the Disclose my personal health, and Disclose my personal health part.

authorization disclose Disclose my personal health, and Disclose my personal health blanks to fill out

In the Name:, Address:, Name:, Address:, Name:, Address:, and I authorize 1-800-MEDICARE to section, emphasize the key data.

Completing authorization disclose step 3

Spell out the rights and obligations of the sides inside the part I authorize 1-800-MEDICARE to, Signature, Telephone Number, Date (mm/dd/yyyy), Print the address of the person, Check here if you are signing as a, and Print the Personal.

part 4 to completing authorization disclose

Review the fields Telephone Number of Personal, and Personal Representative's and next fill them in.

stage 5 to finishing authorization disclose

Step 3: Hit "Done". Now you can upload your PDF file.

Step 4: Get a duplicate of each single form. It will certainly save you time and help you prevent concerns as time goes on. Keep in mind, your data is not used or analyzed by us.

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