Authorization for Release of Medical Information

Authorization for Release of Medical Information for Black Lung Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0034 can be found here:

Documents and Forms

Document Name Document Type
Form CM-936 Authorization for Release of Medical Information Form
CM-936 Authorization For Release of Medical Information CM-936 Proposed 2018.pdf www.dol.gov/owcp/regs/compliance/cm-936.pdf Form

Information Collection (IC) Details

IC Title:	Authorization for Release of Medical Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.407 20 CFR 725.405 20 CFR 725.406 20 CFR 725.408

Information Collection Instruments:

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 Proposed 2018.pdf	http://www.dol.gov/owcp/regs/compliance/cm-936.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: System of Records Notice DOL/OWCP-2	FR Citation: 67 FR 16869

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,000	6,100	900
Annual IC Time Burden (Hours)	583	508	75
Annual IC Cost Burden (Dollars)	0	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.