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Form #
CMS 10106
Form Title
1-800-Medicare Authorization to Disclosure Personal Health Information
Revision Date
2015-07-01
O.M.B. #
0938-0930
O.M.B. Expiration Date
2017-11-30
CMS Manual
N/A
Special Instructions
To fill out an submit the form online. Go to the "Related Links" bleow and click on "Medicare Online Forms"