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Limited Information - CMS

Medicare Beneficiary Services:1-800-MEDICARE (1-800-633-4227) TTY/ TDD:1-877-486-2048 This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health Information .

Disclose my personal health information indefinitely . Disclose my personal health information for a specified period only. beginning: _____(mm/dd/yyyy) and ending: _____(mm/dd/yyyy) 4. Fill in the reason for the disclosure (you may write "at my request"): Fill in the name and address of the person or organization to whom you want Medicare to ...

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