Information Collection

Non-Participant Components Health Care Provide Records Request (Annual follow-up)

IC 221012 under ICR 201604-0925-002 · OMB 0925-0216.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Non-Participant Components Health Care Provide Records Request (Annual follow-up)	Form and Instruction
1 Attachment 5 Medical Record Request Attach 5 Medical Record Request.docx	Form and Instruction

IC Title:

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 and Instruction	1	Attachment 5 Medical Record Request	Attach 5 Medical Record Request.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	30	30
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	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.