Authorization to Release Medical Report to Physician

Forms and Documents

Document	Type	Status	Availability
Form SSA-91 Authorization to Release Medical Report to Physician Form	Form	New	Repair queued
11-7-07 memo.pdf	Supplementary Document	Uploaded 2007-12-04	Available
10-10-07 memo.pdf	Supplementary Document	Uploaded 2007-12-04	Available
Addendum--SSA-91 (Final).doc	Supplementary Document	Uploaded 2007-12-04	Available
SSA-104--CLAIMANT TRAVEL REIMBURSEMENT REQUEST FORM.doc	Supplementary Document	Uploaded 2007-06-21	Repair queued
Cover Letter--CE Appointment Notice.doc	Supplementary Document	Uploaded 2007-06-21	Available
Supporting Statement--SSA-91 (Final).doc	Supporting Statement A	Uploaded 2007-12-04	Available
Addendum--SSA-91.doc	Supplementary Document	Uploaded 2007-04-13	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
179615	Authorization to Release Medical Report to Physician Form	Form	New

ICR Details

OMB Control No: 0960-0761	ICR Reference No: 200704-0960-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization to Release Medical Report to Physician
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/07/2007
	Date Received in OIRA: 06/21/2007
Terms of Clearance: This ICR is approved consistent with memos of 10-10-07 and 11-7-07, revised addendum, and revised supporting statement. SSA shall use the IC entitled "SSA-91 (Final).doc", which is the revised IC.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved
Responses	7,922	0	0
Time Burden (Hours)	660	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: If the claimant, his or her court appointed representative, or a parent of a minor child wants the consultative examination (CE) report sent to the claimant's treating physician, he or she will complete the information requested on Form SSA-91 and send it to SSA for processing. SSA will use the information collected to send the CE report to the authorized physician. Respondents are applicants for disability claims.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1306 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7107	02/14/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 28540	05/21/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Authorization to Release Medical Report to Physician Form	SSA-91, SSA-91	Request to Release Medical Report to a Health Care Provider ,   Authorization to Release Medical Report to Physician Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,922	0	0	7,922	0	0
Annual Time Burden (Hours)	660	0	0	660	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an information collection in use without an OMB control number that will increase the public reporting burden.

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Annual Cost to Federal Government: $12,200

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/21/2007

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