Form CM-936 Authorization for Release of Medical Information (Black

U.S. Department of Labor

Authorization For Release of Medical
Information (Black Lung Benefits)
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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This report is authorized by law (30 U.S.C., 901 at. seq.). While you are not required to respond, your
cooperation is needed to ensure that your claim is given full and proper consideration. Disclosure of a
social security number is voluntary. The failure to disclose such number will not result in the denial of
any right, benefit, or privilege to which you may be entitled.

OMB No. 1215-0057
Expires: 11-30-06

1. Miner's Name

2. Miner's Social Security Number

3. Claimant's Name

4. Relationship to Miner
6. Phone Number

5. Address (Street Number, City, State & ZIP Code)

I hereby authorize any physician, hospital, agency, or other organization, including the National Institute of Occupational Safety
and Health, (NIOSH), Appalachian Laboratory for Occupational Safety and Health (ALOSH), to disclose to the Office of Workers'
Compensation Programs of the U.S. Department of Labor any medical records or other Information about (my) or (the deceased
miner's) medical condition for the purpose of providing evidence related to my claim for benefits under the Black Lung Benefits Act.
7. Signature of Claimant (or person on his behalf)

8. Date (Month, day, year)

Identifying Information for Hospitals
Admission Date(s)

Discharge Date(s)

Birth Date

Give any necessary additional identifying data (such as building, clinic, patient number, etc.)
In-patient
Out-patient

Miner's address at time of hospitalization

Other:

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room N3464, 200 Constitution
Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Form CM-936
Rev. Dec. 1999