SUPPORTING STATEMENT
Authorization for Release of Medical Information (CM-936)
OMB NO. 1215-0057
1. When a person files a claim for black lung benefits, the individual may submit medical information to the Division of Coal Mine Workers' Compensation (DCMWC) to help develop the claim. The CM-936 is a form that gives the claimant's consent for the release of medical information covered by the Privacy Act of 1974, and contains information required by medical institutions and private physicians to enable them to release pertinent medical information. The Black Lung Benefits Act, as amended, 30 USC 901 et. seq. and 20 CFR 725.405 require that all relevant medical evidence be considered before a decision can be made regarding a claimant's eligibility for benefits.
The CM-936 is used by black lung claimants who wish to submit medical evidence to support their claim. The form provides the claimant's consent for medical institutions and private physicians to release medical information to DCMWC. The form may be completed by the claimant and the claims examiner (CE). If the CE completes the form from information already in the claim file, the claimant will need to verify and sign the request.
3. This form is available for downloading from the DCMWC web site by respondents. It may also be completed and submitted online with an electronic signature. The form may be accessed at http://www.dol.gov/esa/regs/compliance/owcp/cm-936.pdf.
4. The Federal Black Lung Program has no other medical release form. Other programs have medical release forms; however, they do not specifically request medical evidence related to the adjudication of black lung claims.
5. This information does not have a significant impact on a substantial number of small entities.
6. If this form were not used, the adjudication of the black lung claim would be incomplete, because pertinent medical data would not be available for consideration.
7. There are no special circumstances for collection of this information.
The Social Security Administration was contacted during the development of the CM-936, because the form is based upon a similar SSA form. Both SSA and DOL obtain this information from claimants, because it is necessary to obtain all the evidence available concerning the claimant’s medical condition. The information is readily available and is only collected once. There have been no complaints concerning the CM-936 or its clarity of instructions, record keeping, disclosure, record format, cost or hour burden or data elements to be recorded, disclosed or reported.
A Federal Register Notice inviting public comment was published on June 1, 2006. No comments were received.
9. Respondents do not receive gifts or payments for furnishing the requested information.
10. The Privacy Act Issuance (ESA-6 and ESA-30) provides for confidentiality of information collected for a claimant's record.
11. There are no questions of a sensitive nature asked on the form.
12. There are approximately 1,200 respondents annually. One form is sent to each respondent, who spends approximately 5 minutes to complete and mail the form. Thus, there is an annual burden of 100 hours.
To estimate the annual cost of the burden hours to the CM-936 respondents, the Federal black lung benefit hourly benefit rate, which is $5.15 per hour, has been applied. Thus, the total annual cost to CM-936 respondents is $515.00 ($5.15 X 100 burden hours).
13. There is no cost burden to respondents or record keepers resulting from the collection of this information.
14. The estimated total cost to the Federal Government for the 1,200 forms is approximately $7,196.50. The cost is computed as follows:
a. Estimated printing and distribution cost is $50.00.
b. Estimated mailing cost is $1,020.00 (includes cost of envelope and stamp, and return, stamped envelope, at a cost of 85 cents per item.)
c. Estimated processing cost is computed at one claims examiner (GS 12/5) spending approximately 5 minutes reviewing the form. (The FY 06 GS Salary Table was used for the hourly wages.)
100 hours x $29.18 per hour = $2,918.00
The estimated burden hour is an adjustment from 125 hours to 100 hours, which is a decrease of -25 hours. The reduction is due to a decrease in the number of persons applying for black lung benefits, and because a change in program regulations in 2001 has reduced the number of claimants for which DCMWC is required to request medical records.
16. There are no plans for publishing statistical data based on this information collection.
17. This request does not seek a waiver from the requirement to display the expiration date.
18. There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | MEMORANDUM FOR: |
| Author | Department of Labor |
| Last Modified By | US Department of Labor |
| File Modified | 2006-08-09 |
| File Created | 2006-08-09 |