Information Collection

0127 NHSC Authorization to Release Information Form

IC 181468 under ICR 200906-0915-001 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form lfp release inform 0127 NHSC Authorization to Release Information Form	Form
lfp release inform lrp release information 0127 release info.doc	Form

IC Title:

0127 NHSC Authorization to Release Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 621

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	lfp release information	lrp release information	0127 release info.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: The Public Health Service and National Health Service Corps Health Care Provider Records System

FR Citation: 58 FR 12968

Number of Respondents: 4,433

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	4,433	2,513	1,920
Annual IC Time Burden (Hours)	443	251	192
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.