Information Collection

Medical Record Request

IC 216974 under ICR 201608-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 AttQ1_MedRecordReleaseForm_English.pdf	Form
Medical Record Release Authorization AttQ2_MedRecordReleaseForm_Spanish.pdf	Form
AttZ1_MedRecPatientRequestLtr_English.pdf Z1 - Record Release Letter	IC Document
AttZ2_MedRecPatientRequestLtr_Spanish.pdf Z2 - Record Release Letter - Spanish	IC Document

IC Title:

Medical Record Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	AttQ1_MedRecordReleaseForm_English.pdf		Yes	No	Paper Only
Form	none	Medical Record Release Authorization	AttQ2_MedRecordReleaseForm_Spanish.pdf		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: 475

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	Previously Approved
Annual Number of Responses for this IC	475	90	385
Annual IC Time Burden (Hours)	119	23	96
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Z1 - Record Release Letter	AttZ1_MedRecPatientRequestLtr_English.pdf	08/02/2016
Z2 - Record Release Letter - Spanish	AttZ2_MedRecPatientRequestLtr_Spanish.pdf	08/02/2016

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