Authorization for Release of Medical Information

Authorization for Release of Medical Information for Black Lung Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0034 can be found here:

Documents and Forms

Document Name Document Type
Form CM-936 Authorization for Release of Medical Information Form
CM-936 Authorization for Release of Medical Information (Black CM-936 Revised.pdf www.dol.gov/esa/owcp/regs/compliance/cm-936.pdf Form

Information Collection (IC) Details

IC Title:	Authorization for Release of Medical Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.405 20 CFR 725.408 20 CFR 725.407 20 CFR 725.406

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-936	Authorization for Release of Medical Information (Black Lung)	CM-936 Revised.pdf	http://www.dol.gov/esa/owcp/regs/compliance/cm-936.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-6 and ESA-30	FR Citation: 67 FR 16869

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.