Authorization for Release of Medical Information

Authorization for Release of Medical Information (Black Lung Benefits)

OMB: 1215-0057

IC ID: 13694

Information Collection (IC) Details

View Information Collection (IC)

Authorization for Release of Medical Information
 
No Modified
 
Voluntary
 
20 CFR 725.405 20 CFR 725.408 20 CFR 725.407 20 CFR 725.406

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) CM-936 06-10-2009.doc http://www.dol.gov/esa/owcp/regs/compliance/cm-936.pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

DOL/ESA-6 and ESA-30  67 FR 16869

900 0
   
Individuals or Households
 
   0 %

  Approved 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 900 0 0 -300 0 1,200
Annual IC Time Burden (Hours) 75 0 0 -25 0 100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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