Centers for Medicare & Medicaid Services (CMS) Edition Form CMS-10106 (03/2026), OMB No. 0938-0930 3 pages

Form CMS-10106 — Authorization to Disclose Personal Health Information

Give 1-800-MEDICARE written permission to discuss your Medicare with the people you name, for as long as you choose.

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Form CMS-10106 · Authorization to Disclose Personal Health Information (1-800-MEDICARE)
The official Centers for Medicare & Medicaid Services (CMS) form, edition Form CMS-10106 (03/2026), OMB No. 0938-0930 — blank
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Form CMS-10106 (2026) Authorization to Disclose Personal Health Information (1-800-MEDICARE) — page 1 of 3
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Fill this form online Blank PDF from Centers for Medicare & Medicaid Services (CMS)

What is Form CMS-10106?

Form CMS-10106, Authorization to Disclose Personal Health Information, is the release form 1-800-MEDICARE needs before it can share your personal health information with anyone other than you. It's how a spouse, adult child, caregiver or helping organization can call about your claims, plan enrollment or premiums on your behalf. The form explains that by law you must give 1-800-MEDICARE this permission in writing first.

You give your details and Medicare Number, then name up to two people or organizations with their addresses. You choose between sharing any information or only certain types (Medicare eligibility, claims, health and drug plan enrollment, premium payments or other information you describe), and whether the permission lasts indefinitely or only for a set period. New York residents answer an extra question about alcohol and drug abuse, mental health treatment and HIV information. You explain briefly why you're giving permission (the form says "At my request" is fine) and sign. A personal representative, for example someone with a Power of Attorney or the executor for a person who has died, can sign instead and gives their own details.

FileIt asks only the questions that apply to you, shows the New York question only for New York residents, splits your Medicare Number, birth date and phone into the form's boxes, and prints your answers on CMS's own PDF (CMS-10106, 03/2026). You can sign with eSignature. FileIt doesn't send it: you mail it to the address on the form, or use your Medicare.gov account instead.

Who fills it
The person with Medicare, or their personal representative.
Sent to
1-800-MEDICARE Written Authorization Dept., PO Box 1270, Lawrence, KS 66044, or online through your Medicare.gov account.
Who can be named
Up to two people or organizations on the form; list more on the back of the printed form.
How long
Indefinitely, or a start and end month you choose. You can cancel it in writing at any time.
Signatures
The person with Medicare, or a personal representative with paperwork attached.
Edition
Form CMS-10106 (03/2026), OMB No. 0938-0930

Who needs to fill out Form CMS-10106?

  • People with Medicare who want a spouse, child or friend to be able to call 1-800-MEDICARE for them.
  • Caregivers who handle a parent's Medicare paperwork and bills.
  • Organizations, such as a counseling program, that help someone with their Medicare questions.
  • Personal representatives acting under a Power of Attorney or guardianship.
  • Executors and others with legal authority who need information about a person with Medicare who has died.

When to use Form CMS-10106

  • Before a family member or helper needs to speak with 1-800-MEDICARE about your claims, plans or premiums.
  • When you start helping a parent or relative manage their Medicare.
  • When you're settling the Medicare affairs of someone who has died and have the legal documents to do so.
  • To limit sharing to certain information or a set period, or to replace an earlier authorization.

What you need before you start

  • The full name, Medicare Number and date of birth of the person with Medicare.
  • Their mailing address, phone number and (optionally) email.
  • The name and mailing address of each person or organization that may receive information.
  • Which information to share: everything, or the specific types.
  • How long the permission should last: indefinitely, or a start and end month.
  • A short reason for giving permission.
  • For a personal representative: their name, address, phone, relationship, and a copy of the paperwork that lets them act.

What’s on Form CMS-10106

The 2026 edition has 3 pages. FileIt asks for it in 5 parts, and it is signed by Person with medicare (or personal representative):

  1. Information about the person with MedicarePerson with medicare (or personal representative)
  2. Who can get the informationPerson with medicare (or personal representative)
  3. What 1-800-MEDICARE can sharePerson with medicare (or personal representative)
  4. How long, and whyPerson with medicare (or personal representative)
  5. Signing as a personal representativePerson with medicare (or personal representative)

How to fill out Form CMS-10106, step by step

1 The person with Medicare

Enter the first, middle and last name, suffix, Medicare Number, date of birth, mailing address, phone and email of the person whose information will be shared.

2 Who can get the information

Name person or organization 1 and its mailing address, and a second one if you like. The form says to list any more, with addresses, on the back of the printed form.

3 What may be shared

Check only one: any information, or limited information. For limited information, tick each type: eligibility, claims, health and drug plan enrollment, premium payments, or other information you write in.

4 New York residents

If the person lives in New York, say yes or no to sharing information about alcohol and drug abuse, mental health treatment or HIV, which New York law protects separately.

5 How long and why

Choose indefinitely, or a start and end month. Then explain why you're giving permission; "At my request" is enough, the form says.

6 Signature and personal representative

Sign and date the form. If you're signing as a personal representative, FileIt ticks the representative box, asks for your details and relationship, and reminds you to attach your paperwork.

Common mistakes to avoid

  • Choosing "limited information" without ticking any type to share.
  • Giving an end date earlier than the start date, or one that has already passed.
  • Signing as a representative without attaching the Power of Attorney or other paperwork.
  • For someone who has died, leaving out the legal documents that give you authority, such as Executor papers or Letters of Administration.
  • Mailing the form to the CMS address in the paperwork notice instead of the 1-800-MEDICARE address. The form warns this will significantly delay it.
  • Forgetting to answer the New York question when the person lives in New York.

After you fill it out

Sign the form and mail it to 1-800-MEDICARE Written Authorization Dept., PO Box 1270, Lawrence, KS 66044. Include any representative or estate documents. The form also mentions submitting it online through your Medicare.gov account for faster service.

To change or cancel the authorization later, write to the same address. The form says this cancels it, except for information already released.

Keep the signed authorization in your FileIt vault, shared with the family members who help you, so everyone knows what 1-800-MEDICARE can discuss.

Fill out Form CMS-10106 online with FileIt

  1. Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
  2. Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 46 fields in all. Your answers save as you go.
  3. Check the live preview. Watch your answers land on the real Centers for Medicare & Medicaid Services (CMS) form, and let FileIt do any worksheet arithmetic.
  4. Generate the official PDF. FileIt prints your answers into the agency’s own PDF and files it in that person’s folder in your vault. Sign it, or send it for e-signature.

FileIt fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.

Start Form CMS-10106 now — it’s free

Form CMS-10106: frequently asked questions

What does Form CMS-10106 do?

It gives 1-800-MEDICARE written permission to share your personal health information with the people or organizations you name on it.

Where do I send CMS-10106?

The form gives 1-800-MEDICARE Written Authorization Dept., PO Box 1270, Lawrence, KS 66044, and says you can submit it online through your secure Medicare.gov account for faster service.

Can I limit what Medicare shares?

Yes. Choose limited information and tick only the types you want shared, such as claims or premium payments, or describe other information.

How long does the authorization last?

As long as you choose: indefinitely, or for a period with start and end dates. The form notes that your state may have different limits.

Can I cancel it?

Yes. The form says you can change or cancel it at any time by writing to the 1-800-MEDICARE address; information already released isn't affected.

Can I use it for a family member who died?

Yes, if you have the legal right to the information. Sign as a personal representative and include the legal documentation, such as Executor papers or a Letter of Administration with a court stamp and judge's signature.

How many people can I name?

The form has room for two people or organizations. It says to list more, with their name and address, on the back of the form.

Official sources

FileIt is not affiliated with or endorsed by Centers for Medicare & Medicaid Services (CMS) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-19.

Fill out Form CMS-10106 online