Information Collection

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

IC 42641 under ICR 200111-3095-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	Authorization for Release of Military Medical Patient Records, 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	13055	No	No
Form	13075	No	No
Form	13042	No	No
Form	NA-FORMS-13036	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	Previously Approved
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.