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Authorization to Disclose Personal Health Information Form

   
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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 to allow 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:

  • Click the 'Download Medicare Authorization to Disclose Personal Health Information Form' link in the Related Materials section to download this form.
  • You will need to include a copy of the legal documentation which indicates your authority to make a request for information. (For example: Executor/Executrix papers, a Letter of Testamentary or Administration with acourt stamp and judge's signature, or personal representative papers with a courtstamp and judge and/or county clerk's signature.)
  • You will also need to explain your relationship to the beneficiary.
  • Mailing instructions are included on the form.

If you are completing this form as a personal representative:

  • Click the 'Download Medicare Authorization to Disclose Personal Health Information Form' link in the Related Materials section to download this form.
  • Mailing instructions are included on the form.

This form is a 3-step process and will take approximately 10 - 15 minutes to complete.



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