Authorization for Release of Medical Information

Authorization for Release of Medical Information for Black Lung Benefits

OMB: 1240-0034

IC ID: 13694

Information Collection (IC) Details

View Information Collection (IC)

Authorization for Release of Medical Information
 
No Modified
 
Voluntary
 
20 CFR 725.405 20 CFR 725.408 20 CFR 725.407 20 CFR 725.406

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CM-936 Authorization For Release of Medical Information CM-936 February 2016.pdf http://www.dol.gov/owcp/regs/compliance/cm-936.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

DOL/ESA-6 and ESA-30  67 FR 16869

900 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 900 0 0 0 0 900
Annual IC Time Burden (Hours) 75 0 0 0 0 75
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy