Medicare Consent to Release Form

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A Medicare consent to release form is a document that grants Medicare permission to share someone’s protected health information with a third party. Individuals enrolled in Medicare (or their personal representatives) can use the form to specify what information they want to share, who can access it, and for how long.

Medicare Consent to Release Form

A Medicare consent to release form is a document that grants Medicare permission to share someone’s protected health information with a third party. Individuals enrolled in Medicare (or their personal representatives) can use the form to specify what information they want to share, who can access it, and for how long.

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Last updated April 4th, 2024

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A Medicare consent to release form is a document that grants Medicare permission to share someone’s protected health information with a third party. Individuals enrolled in Medicare (or their personal representatives) can use the form to specify what information they want to share, who can access it, and for how long.

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How to Complete a Medicare Release (6 Steps)

1. Identify the Enrollee

The identity of the person enrolled in Medicare must be stated on the release form, along with the individual’s address, date of birth, and Medicare identification number.

2. Choose the Information to be Shared

Medicare will need to know if the enrollee wants to share all of their Medicare information or specific documents only.

3. Set a Duration

The completed document must mention how long the enrollee wants their protected health information to be shared, whether for an indefinite period or a specific time frame only.

4. Explain the Purpose of the Release

A Medicare release form must briefly explain why the enrollee wants to share their protected health information.

5. Name the Recipients

The individuals or organizations authorized to access the enrollee’s Medicare information must be listed. When an organization is provided, a specific individual within that organization must also be identified.

6. Sign and Submit

After filling in the required information, the enrollee or their personal representative must sign the form and file it with Medicare. The document can be submitted electronically using the Medicare website or by mail at the following address:

1-800-MEDICARE
Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044