Information Collection

Authorization to Release Medical Report to Physician Form

IC 179615 under ICR 201006-0960-011 · OMB 0960-0761.

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 Authorization to Release Medical Report to Physician Form	Form
SSA-91 Authorization to Release Medical Report to Physician For SSA-91 (revised).pdf	Form
SSA-91 (current).pdf SSA-91(current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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				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	Previously Approved
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
SSA-91(current)		09/07/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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