Medicare Authorization to Disclose Personal Health Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0930 can be found here:

Documents and Forms

Document Name Document Type
Form OMB no. 0938-0930 Medicare Authorization to Disclose Personal Health Information Form and Instruction
clean Information to Help You Fill Out the.docx Instruction
OMB no. 0938-0930 Medicare Authorization to Disclose Personal Health Infor clean fillableauthform_v1 1d_02022011.docx Form and Instruction
clean Information to Help You Fill Out the.docx Information to Help You Fill Out the IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Authorization to Disclose Personal Health Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OMB no. 0938-0930	Medicare Authorization to Disclose Personal Health Information	clean fillableauthform_v1 1d_02022011.docx		No	No	Fillable Fileable
Instruction			clean Information to Help You Fill Out the.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,004,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,004,000	4,000	1,000,000
Annual IC Time Burden (Hours)	251,000	1,000	250,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Information to Help You Fill Out the	clean Information to Help You Fill Out the.docx	02/21/2011

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