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

U.S. Department of Labor

Authorization For Release of Medical
Information (Black Lung Benefits)
Reset

Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
OMB No. 1240-0034
Expires: xx-xx-xx

Print

1. Miner's First Name

M. I.

Last Name

2. Miner's SSN

3. Claimant's First Name

M. I.

Last Name

4. Relationship to Miner

5. Address
State

City

Zip

Phone

I hereby authorize any physician, hospital, agency, or other organization, including the National Institute of Occupational Safety and Health,
(NIOSH), Appalachian Laboratory for Occupational Safety and Health (ALOSH), 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.
8. Date (Month, day, year)

7. Signature of Claimant (or person on his behalf)

Identifying Information for Hospitals
Admission Date(s)

Birth Date

Discharge Date(s)

Give any necessary additional identifying data (such as building, clinic, patient number, etc.)
In-patient
Out-patient

Miner's address at time of hospitalization
Street Address
City

State

Zip

Other:

CM-936 (Rev. 09-12)

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
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. 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 C3526, 200 Constitution Avenue,
N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help
from DCMWC in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will
provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of
adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this
assistance.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

CM-936 Page 2 (Rev. 09-12)