#Medicare standard form 5510 instructions free
If you have any questions or need additional assistance, please feel free to call us at 1-800- MEDICARE (1-80). Option 2 To exclude the information listed above, check the box "Exclude information about alcohol and drug abuse, mental health treatment, and HIV". Option 1 To include all information, check the box: "All information, including information about alcohol and drug abuse, mental health treatment, and HIV". Instructions for Completing Section 2C of the Authorization Form: Please select one of the following options. For example, you could write "payment information".
You may also check any of the remaining boxes and include any additional limitations in the space provided. Because of New York's laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and HIV, there are special instructions for how you, as a New York resident, should complete this form.įor question 2A, check the box for Limited Information, even if you want to authorize Medicare to release any and all of your personal health information. The New York State Public Health Law protects information that reasonably could identify someone as having HIV symptoms or infection, and information regarding a person's contacts. Lawrence, KS 66044 For New York Medicare Beneficiaries ONLY Medicare CCO, Written Authorization Dept. Where to Return Your Completed Authorization Forms:Īfter you complete and sign the authorization form, return it to the address below: This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information.
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