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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.