You must give Medicare written permission (an “authorization”) before Medicare can use or disclose your personal medical information for any purpose other than those stated in the Medicare & You handbook. It is your right to revoke your written permission at any time, except if Medicare has already taken action based on it.
If you’re requesting personal health information for a deceased beneficiary, please include a copy of the legal documentation confirming your authority. (For example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a judge’s signature, a Letter of Testamentary or Administration with a court stamp and judge’s signature, or personal representative papers with a court stamp and judge’s signature.) Also, please explain your relationship to the beneficiary.
To download this form call Medicare Beneficiary Services at 800-MEDICARE or search for the form “Medicare CMS 10106”