Information Collection

Access of Individuals to Protected Health Information (submitting requests for individuals to direct copies of ePHI to plans and providers)

IC 244625 under ICR 202011-0945-001 · OMB 0945-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0003 can be found here:

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Information Collection (IC) Details

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IC Title:	Access of Individuals to Protected Health Information (submitting requests for individuals to direct copies of ePHI to plans and providers)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 164.524

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation: 86 FR 6446

Number of Respondents: 92,250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	92,250	92,250
Annual IC Time Burden (Hours)	5,381	5,381
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.