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You can view and print forms online by accessing the links below. Simply click on the name of the form to view or download (print) a copy.
Please call 1-800-MEDICARE (1-800-MEDICARE) for assistance filling out these forms. TTY users should call 1-877-486-2048.
All of the forms are Adobe Acrobat version 7.0.5 accessible. You will need Adobe Reader software to view the files.
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Please note that CMS Form 10106, Medicare Authorization to Disclose Personal Health Information, can be completed and printed using
Adobe Acrobat Reader. You have the ability to enter your information and then print the form to be mailed in.
If you are signing this form as a personal representative (for example, Power of Attorney) for the person with Medicare, you are attesting that you have the legal authority to sign this document on their behalf. CMS reserves the right to request copies of the documentation or you must submit the documentation upon request. If you have questions, please contact 1-800-MEDICARE (1-800-633-4227).
Title
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Form Number
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Purpose
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Language Availability
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Medicare Authorization to Disclose Personal Health Information Note: If you live in the state of New York, please call 1-800 MEDICARE for additional instructions prior to mailing the authorization form.
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CMS-10106
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Authorizes CMS to disclose personal health information to persons or organizations that you designate.
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English
Spanish*
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Patient’s Request for Medical Payment |
CMS-1490S
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Used by the beneficiary to file a claim with Medicare for services and/or supplies received.
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English
Spanish
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*To view the Spanish version of this form, click on the 'Vea en Español' link at the top of the page.
Medicare Appeals Forms
All CMS forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp
Page Last Updated: September 15, 2008
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