Information Collection

Medical Record Request

IC 216974 under ICR 201505-0920-009 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medical Record Request	Form
Medical Record Release Authorization Att O1_MedRecordReleaseForm_English.docx	Form
Medical Record Release Authorization Att O2_MedRecordReleaseForm_Aug_Spanish.docx	Form
AttW1_MedRecPatientRequestLtr_English_June 2015(1).pdf W1 - Record Release Letter	IC Document
AttW2_MedRecPatientRequestLtr_Spanish.pdf W2 - Record Release Letter - Spanish	IC Document

IC Title:

Medical Record Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	none	Medical Record Release Authorization	Att O1_MedRecordReleaseForm_English.docx		Yes	No	Paper Only
Form	none	Medical Record Release Authorization	Att O2_MedRecordReleaseForm_Aug_Spanish.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 385

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	385	385
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
W1 - Record Release Letter	AttW1_MedRecPatientRequestLtr_English_June 2015(1).pdf	06/10/2015
W2 - Record Release Letter - Spanish	AttW2_MedRecPatientRequestLtr_Spanish.pdf	06/10/2015

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