OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for and Authorization to Release Medical Records or Health Information, etc

ICR 201407-2900-009 · OMB 2900-0260 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 10-5345a Request for and Authorization to Release Medical Records or Health Information, etc Form Modified Available
2900-0260 sub. change (2).docx Justification for No Material/Nonsubstantive Change Uploaded 2014-07-10 Available
2900-0260_justification (v6.1).docx Supporting Statement A Uploaded 2013-02-28 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28503 Request for and Authorization to Release Medical Records or Health Information, etc Form Modified
ICR Details
2900-0260 201407-2900-009
Historical Active 201206-2900-012
VA 2900-0260
Request for and Authorization to Release Medical Records or Health Information, etc
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 12/09/2014
Retrieve Notice of Action (NOA) 10/02/2014
  Inventory as of this Action Requested Previously Approved
03/31/2016 03/31/2016 03/31/2016
1,311,000 0 1,311,000
60,550 0 60,550
0 0 0
These forms are used to obtain written patient consent for release of medical records to individuals and third parties when the information is considered protected, the information is covered by confidentiality, privacy or HIPAA statutes, or the individual requests copies of their own records.
US Code: 38 USC 7332 Name of Law: Confidentiality of certain medical records
   US Code: 38 USC 5701 Name of Law: Confidential nature of claims
  
None
Not associated with rulemaking
  77 FR 42555 07/19/2012
77 FR 64387 10/19/2012
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,311,000 1,311,000 0 0 0 0
Annual Time Burden (Hours) 60,550 60,550 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
VA Forms 10-0525A and 10-0485 are new forms that contribute to the Program Change and increase in burden hours. Also, the time to complete VA Form 10-5345 was reduced from 3 minutes to 2 minutes.
$13,676,313
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/02/2014