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Federal forms, ICRs, and supporting documents

Information Collection

Medical Records Privacy Act Release Form

IC 255165 under ICR 202208-1651-001 · OMB 1651-0144.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Medical Records Privacy Act Release Form
 
No New
 
Required to Obtain or Retain Benefits
 
5 CFR 339.301 5 CFR 339.305

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 3400 Hiring Center Medical Records Privacy Act Release Form CBP Form 3400 Medical Records Release Form.pdf Yes Yes Fillable Fileable Signable

Homeland Security Border and Transportation Security

 

104 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 208 0 208 0 0 0
Annual IC Time Burden (Hours) 52 0 52 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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