Request For And Consent To Release Of Drug Abuse, Alcoholism, Or Alcohol Abuse Or Sickle Cell Anemia Information From Medical Records

REQUEST FOR AND CONSENT TO RELEASE OF DRUG ABUSE, ALCOHOLISM, OR ALCOHOL ABUSE OR SICKLE CELL ANEMIA INFORMATION FROM MEDICAL RECORDS

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0260 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	REQUEST FOR AND CONSENT TO RELEASE OF DRUG ABUSE, ALCOHOLISM, OR ALCOHOL ABUSE OR SICKLE CELL ANEMIA INFORMATION FROM MEDICAL RECORDS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-5345				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 246,404	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	492,808	492,808
Annual IC Time Burden (Hours)	3,545	3,545
Annual IC Cost Burden (Dollars)	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.