Information Collection

Authorization for Release of Medical Information

IC 13694 under ICR 202409-1240-002 · OMB 1240-0034.

Documents and Forms

Document Name Document Type
Form CM-936 Authorization for Release of Medical Information Form
CM-936 Authorization For Release Of Medical Information (Black New proposed form CM 936.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-936 Authorization For Release Of Medical Information (Black New proposed form CM 936.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization for Release of Medical Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.405 20 CFR 725.407 20 CFR 725.406 20 CFR 725.408

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-936	Authorization For Release Of Medical Information (Black Lung Benefits)	New proposed form CM 936.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: System of Records Notice DOL/OWCP-2	FR Citation: 67 FR 16869

Number of Respondents: 5,990	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 2 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,990	990	5,000
Annual IC Time Burden (Hours)	1,995	1,578	417
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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