Information Collection

Authorization to Release Medical Report to Physician Form

IC 179615 under ICR 200704-0960-010 · OMB 0960-0761.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0761 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-91 Authorization to Release Medical Report to Physician Form Form
SSA-91 Authorization to Release Medical Report to Physician For SSA-91--AUTHORIZATION TO RELEASE MEDICAL REPORT TO PHYSICIAN FORM.doc Form
SSA-91 Request to Release Medical Report to a Health Care Provi SSA-91 (Final).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization to Release Medical Report to Physician Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.100 20 CFR 401.55

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-91	Request to Release Medical Report to a Health Care Provider	SSA-91 (Final).doc		No		Paper Only
Form	SSA-91	Authorization to Release Medical Report to Physician Form	SSA-91--AUTHORIZATION TO RELEASE MEDICAL REPORT TO PHYSICIAN FORM.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,922	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,922	7,922
Annual IC Time Burden (Hours)	660	660
Annual IC Cost Burden (Dollars)	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.