Information Collection

Privacy Act Release Authorization Form

IC 181468 under ICR 201311-0915-003 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Privacy Act Release Authorization Form	Form and Instruction
2 Privacy Act Release Authorization Form FY13 NHSC LRP Privacy Act Release Authorization Form.pdf	Form and Instruction

IC Title:

Privacy Act Release Authorization Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 621

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 and Instruction	2	Privacy Act Release Authorization Form	FY13 NHSC LRP Privacy Act Release Authorization Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: The Public Health Service and National Health Service Corps Health Care Provider Records System

FR Citation: 58 FR 12968

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	-5,075	5,175
Annual IC Time Burden (Hours)	10	-508	518
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.