Information Collection

Authorization for Release of Military Medical Patient Records, Request for Information Needed to Locate Medical Records, Request for Information Needed to Reconstruct Medical Data, Questionnaire

IC 32544 under ICR 199910-3095-002 · OMB 3095-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3095-0039 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	Authorization for Release of Military Medical Patient Records, Request for Information Needed to Locate Medical Records, Request for Information Needed to Reconstruct Medical Data, Questionnaire	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.	Available Electronically?	Can Be Submitted Electronically?
Form	NA-FORMS-13036	No	No
Form	13042	No	No
Form	13055	No	No
Form	13075	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 79,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	79,800	79,800
Annual IC Time Burden (Hours)	6,650	6,650
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.