Authorization for Use or Disclosure of Health Information Form

Countermeasures Injury Compensation Program (CICP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Authorization for Use or Disclosure of Health Information Form Form and Instruction
1 Authorization for Use or Disclosure of Health Informatio 2 CICP Authorization Form.doc Form and Instruction
2 CICP Authorization Form Instructions.doc Instructions - Authorization for Use or Disclosure of Health Information Form IC Document

Information Collection (IC) Details

IC Title:	Authorization for Use or Disclosure of Health Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	Authorization for Use or Disclosure of Health Information Form	2 CICP Authorization Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions - Authorization for Use or Disclosure of Health Information Form	2 CICP Authorization Form Instructions.doc	08/27/2013

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