Best Results Organizing

So, that’s why I’m writing this post, so that if you or someone you know is enrolled in Medicare, you (or they) can jump right on this.

WHAT TO KNOW ABOUT THE CMS-10106

The first thing to know about the long-windedly named 1-800-MEDICARE Authorization to Disclose Personal Health Information Form (CMS-10106) is that it’s a fillable PDF.

For those unfamiliar, that’s a digital form that allows you to type the information right into the blank fields on the screen so that when it’s printed, the information you typed is blended with the form provided, as if you were using a typewriter and typing right on the paper. One supposes that Medicare doesn’t want people to print and fill the blank documents by hand to prevent confusion caused by messy handwriting.

Open the CMS-10106 instructions and form on a computer. (While I have not tested all browser options, the fillable PDF function does not work on my iPhone or iPad.)

The form has only six questions (with a few sub-sections) and they are pretty self-explanatory. 

Q1: First, fill in the name, Medicare number, and birthday of the person who is a Medicare beneficiary. That’s either you, or if you’re the person with Power of Attorney for a person with Medicare, you’ll put their information. (You’ll get to identify yourself as the Medicare beneficiary’s personal representative later on in the form.)

Q2: Next, you get to choose whether you’re allowing all information to be disclosed, or only a limited amount.

You can specify whether Medicare can disclose information related to any or all of the categories mentioned: eligibility, claims, plan enrollment, payment of premiums, and/or other information, including payments to beneficiaries.

(There is a special sub-question just for New York residents, allowing them to grant or withhold authorization to discuss alcohol and drug abuse, mental health treatment, and HIV status. If you are not a New York State resident, you will skip this question.)

Q3: At this point, you get to decide whether you want authorize Medicare to disclose your personal information indefinitely, or only for a limited period of time (and you would provide a start and end date).

In most cases, you would grant authorization indefinitely to your spouse, adult child, or loved one. However, if you’re a singleton and asking a good friend (but perhaps not your BFF) to help you with these things, you might want to date-limit authorization. (Also, as you’ll see below, you may have reasons to grant authorization for a limited period to representatives of an agency or organization.) 

Note: even if you grant indefinite authorization, your state may have separate regulations regarding how long authorization stands. Yes, that lack of uniformity between states and a federal agency is another example of how wackadoodle red tape can be.

Q4: The fourth question could prove a little confusing, so Medicare offers a twinge of help. The question reads, “Fill in the reason for the disclosure (you may write “at my request”):” 

It’s good that they’ve added that parenthetical option, because most people would end up filling the two blank lines with some variation on, “Because I’m having this yucky surgery and my brain is going to be floopy for a while and I’ll be in the hospital and then in a rehab facility without good cell service, I want my cousin Bernice to be able to talk to Medicare for me.” And that won’t really help anyone. Just write, “at my request” and be done with it.

Q5: The fifth question gives you the opportunity to name two people (and provide their addresses) to whom Medicare can disclose your personal information. If you have named primary and secondary “agents” as your Powers of Attorney, these would be the people you’d most likely list here. (You can add more names on a separate sheet of paper.)

Note: Medicare allows you to list organizations instead of, or in addition to, individual persons; for example, if you’ve hired a professional financial organizer, daily money manager, geriatric care manager, or elder attorney, you might want to list the company/service so that assigned team members can provide assistance.

Another reason you might want to list a particular organization is if you’ve been injured in an accident. Let’s say you need to make a personal injury claim because your neighbor’s giant skeleton display for Halloween falls on you.

If you are making a claim, you have to prove that you sustained injuries, and your medical records (including Medicare records) may be required to support your claim and get your neighbor’s insurance to pay. Authorizing Medicare to talk to your neighbor’s insurance company may help speed things along.

Q6: The final question is formatted a little differently. First, there’s the official authorization statement:

“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.”

Underneath, there are fields for a signature (the only field you will leave blank until after you print the document), phone number, and date you’re filling out the form. Then there’s a box to list the complete address of the person with Medicare (that is, the beneficiary).

Note: if you’re not the beneficiary (rather, you’re the one helping the person with Medicare), you’ll check the box that says, “Check here if you are signing as a personal representative and complete below. Please attach the appropriate documentation (for example, Power of Attorney).”

Then you’ll provide your own address, telephone number, and your relationship to the beneficiary, and you’ll attach a copy of the Power of Attorney documents to prove you are authorized to be a personal representative. (Again, you’re authorizing yourself to authorize yourself to talk to Medicare. Yes, it’s weird.)

Remember, the person with Medicare is the beneficiary; the person helping the beneficiary is the personal representative!

Once you complete the entire form, there’s a grey PRINT FORM button at the bottom. Click it, and then sign on the signature line for question #6. Remember, I said the fillable PDF wouldn’t let you type anything there? That’s because, of course, you have to hand-sign the document. You can’t use Adobe or Apple Preview’s digital signature feature because the form won’t let you click there. 

Make a copy of the CMS-10106 for your own records and mail the signed, blended form to:

Medicare CCO, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044

WHAT IF I CHANGE MY MIND?

At any time, even if you’ve granted indefinite authorization or the ending date of the limited authorization has not yet occurred, you can revoke your authorization.

This doesn’t have to seem like a mean thing. I mean, sure, you could be in a huge fight with your Cousin Bernice because she said the potato salad you brought to the last family reunion wasn’t as good as hers, and you’ve decided you don’t want her to be authorized to talk to Medicare on your behalf.

More likely, however, you may have divorced your spouse or separated from your significant other, or the person you’d previously assigned authorization to might be ill themselves, or otherwise unavailable. Or you may have just moved to a different city, where it wouldn’t make sense for the formerly authorized person to help you with your Medicare issues.

How To Revoke Authorization

To revoke authorization, you must notify Medicare in writing and send it to the Lawrence, Kansas address, above. There’s no form, nor is there a sample letter. I would advise writing a simple letter (in the format of a business letter as you learned in school, along the lines of:

[Your Street Address]
[Your City/State/Zip] 

[DATE]

To Whom It May Concern:

I, [YOUR NAME]/Medicare #[YOUR MEDICARE NUMBER] hereby revoke my authorization to disclose personal health information, previously granted on [DATE you signed the original CMS-10106], to [insert NAME OF PERSONS to whom you granted authorization].

I may be reached at [insert PHONE NUMBER] if there are any questions.

Sincerely,

signature

[YOUR NAME]

Be sure to sign the letter (between the “Sincerely” and the typed version of your name). If you’re old enough to receive Medicare, you probably know how to write a business letter in block format. If you’re GenZ or a younger Millennial, you’re welcome.

WHAT IF THE MEDICARE BENEFICIARY HAS PASSED AWAY?

There are times when a personal representative will not have Power of Attorney status. If the beneficiary is deceased (let’s say, it’s your great-grandfather), you may still use this same form, but you will need to add copies of different legal documents. This is because Power of Attorney documents “do not survive” — in other words, they don’t retain power — after an individual’s death.

So, instead of PoA documents, you might need to attach copies of “personal representative paperwork” that signifies that you are the executor of the deceased’s will or the administrator of an estate or have a similar role. Documents might include:

• a court document that states you are the deceased’s next of kin*
• a Letter of Testamentary (or Letter of Administration)*
• other personal representative papers indicating you are the executor or administrator*

*In any of the above cases, the documents will need to have a court stamp and judge’s signature.

You’ll also want to include a statement of how you’re related to the deceased Medicare beneficiary.

September is National Preparedness Month, and Ready.gov has a wide variety of information on how to plan ahead and prepare for disasters. However, being “ready” involves being prepared for far more than natural disasters. While I encourage you to visit Ready.gov, I also urge you to (re)visit the Paper Doll posts linked at the top of this page so that you have all the essential Very Important Papers you need, securely organized and accessible.