Information Collection

Authorization to Release Information Form

IC 196033 under ICR 201403-0915-003 · OMB 0915-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Authorization to Release Information Form Form
continuation-application-user-guide[1].doc Instruction
1 Authorization to Release Information Form Authorization to Release Information.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization to Release Information 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 Part 57 Section 312 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Authorization to Release Information Form	Authorization to Release Information.pdf		Yes	Yes	Fillable Fileable
Instruction			continuation-application-user-guide[1].doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Public Health Service and National Health Service Corps Scholarship/Loan Repayment Participants Records System	FR Citation: 58 FR 12868

Number of Respondents: 5,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,500	-2,500	8,000
Annual IC Time Burden (Hours)	550	-250	800
Annual IC Cost Burden (Dollars)	0	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.