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Medicare Authorization to Disclose Personal Health Information

PERMISSION TO CONTACT FORM

 
How can someone call 1-800-MEDICARE for me?
Medicare won’t give out your personal health information to others through 1-800-MEDICARE unless you give permission. You can either give verbal permission over the phone for the customer service representative to speak with someone else on your behalf, or fill out an authorization form in advance. There are 2 ways to fill out the
“Medicare Authorization to Disclose Personal Health Information” form:
Fill out and submit an electronic authorization form online at
Medicare.gov/forms-help-and-resources/forms/medicare-forms.html
.
This lets someone call and speak immediately on your behalf.
Download, fill out, print, and sign the form from
Medicare.gov/medicareonlineforms/publicforms/cms10106.pdf
, then mail it to:
Medicare BCC
Written Authorization Dept.
P.O. Box 1270
Lawrence, KS 66044
If you submit the form by mail, it generally takes a few weeks before permission is in place
for someone to speak on your behalf.
You can call 1-800-MEDICARE for help filling out the form
 
HERE IS THE FORM:
 

Permission to Contact Form

 
https://www.medicare.gov/Pubs/pdf/11386-Medicare-questions-answered.pdf