Information Collection

Follow-up to Request for Clinical & Medical Treatment Records

IC 214198 under ICR 201706-3095-004 · OMB 3095-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3095-0039 can be found here:

Documents and Forms

Document Name Document Type
Form NA Form 13177 Follow-up to Request for Clinical & Medical Treatment Records Form and Instruction
NA Form 13177 Follow-up to Request for Clinical & Medical Treatment Re NA13177_3095-0039.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Follow-up to Request for Clinical & Medical Treatment Records	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	NA Form 13177	Follow-up to Request for Clinical & Medical Treatment Records	NA13177_3095-0039.pdf		Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Cultural and Historic Preservation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.