Information Collection

Authorization For Disclosure Of Medical Information

IC 157142 under ICR 198502-3207-003 · OMB 3207-0003.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	PCC 1207	No	No
Form	3572	No	No
Form	5235	No	No
Form	5236	No	No
Form	5237	No	No
Form	5238	No	No
Form	8200	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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