Information Collection

Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information

IC 28503 under ICR 200512-2900-006 · OMB 2900-0260.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information	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				Yes	Yes
Form	10-5345A				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,000,000	500,000	500,000
Annual IC Time Burden (Hours)	33,333	16,666	16,667
Annual IC Cost Burden (Dollars)	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.