Authorization For Disclosure Of Medical Information

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

OMB: 3207-0003

IC ID: 157142

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no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
 
No Migrated
 
Required to Obtain or Retain Benefits
 

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


    

50 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 50 0 0 50 0 0
Annual IC Time Burden (Hours) 8 0 0 8 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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