Authorization for Release of Medical Information

Authorization for Release of Medical Information (Black Lung Benefits)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0057 can be found here:

Documents and Forms

Document Name Document Type
Form CM-936 Authorization for Release of Medical Information Form
CM-936 Authorization for Release of Medical Information (Black cm-936.pdf www.dol.gov/esa/regs/compliance/owcp/cm-936 Form

Information Collection (IC) Details

IC Title:	Authorization for Release of Medical Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.406 20 CFR 725.407 20 CFR 725.405 20 CFR 725.408

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-936	Authorization for Release of Medical Information (Black Lung Benefits)	cm-936.pdf	http://www.dol.gov/esa/regs/compliance/owcp/cm-936	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-6 and ESA-30	FR Citation: 67 FR 67

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,200	-300	1,500
Annual IC Time Burden (Hours)	100	-25	125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.