Information Collection

Authorization for Release of Medical Information

IC 13694 under ICR 200608-1215-004 · OMB 1215-0057.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.