Form CM-936 Authorization for Release of Medical Information (Black

Authorization For Release of Medical Information (Black Lung Benefits)		U. S. Department of Labor Employment Standards Administration Office of Workers’ Compensation Program Division of Coal Mine Workers’ Compensation
						OMB No. 1215-0057 Expires: 10/31/2009
1. Miner's Name			2. Miner's Social Security Number
3. Claimant's Name (if different from Miner)			4. Relationship To Miner
5. Address (Street Number, City, State and Zip Code)					6. Phone Number
I hereby authorize any physician, hospital, agency, or other organization, including the National Institutes of Occupational Safety and Health (NIOSH), to disclose to the Office of Workers' Compensation Programs of the U.S. Department of Labor any medical records or other information about my or the deceased miner's medical condition for the purpose of providing evidence related to my claim for benefits under the Black Lung Benefits Act.
7. Signature of Claimant (or person on his behalf)				8. Date (Month, Day, Year)
Identifying Information for Hospitals
Admission Date(s)	Discharge Date(s)						Birth Date
Give any necessary additional identifying data (such as building, clinic, patient number, etc.)  In-patient  Out-patient
Miner's Address at time of hospitalization:
Other:

Form CM-936

Rev. April 2009

Privacy Act Statement

The following information is provided in accordance with the Privacy Act of 1974 (5 U.S.C. 552a), as amended. (1) Collection of this information is authorized by the Black Lung Benefits Act, as amended (30 USC 901 et seq.) and by 20 CFR 725.405. (2) The information in this form will be used to authorize medical treatment providers to release information about the miner to the Department of Labor pertinent to the black lung claim. We are authorized to collect a Social Security Number (SSN) under Executive Order 9397 (November 22, 1943) to help identify individuals in agency records and keep records accurate because other people may have the same name and birth date. Disclosure of the coal miner’s social security number and the completion of this form are voluntary. While you are not required to respond, your cooperation is needed to ensure that your claim is given full and proper consideration. Failure to provide the release of medical documentation may exclude relevant medical information from consideration in the black lung claim. The failure to disclose the miner’s social security number will not result in the denial of any right, benefit or privilege to which you may be entitled. (3) Information may be used by other agencies, government contractors, or persons in handling matters related, directly or indirectly, in processing this form. (4) Furnishing all requested information will facilitate accurate and timely processing of the black lung claim.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers’ Compensation, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE