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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.