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Authorization For Disclosure Of Medical Information
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
OMB: 3207-0003
IC ID: 157142
OMB.report
PANAMA
OMB 3207-0003
ICR 198502-3207-003
IC 157142
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
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:
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
Federal Enterprise Architecture Business Reference Module
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 %
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
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.