Authorization for Use or Disclosure of Health Information Form

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 208416

Information Collection (IC) Details

View Information Collection (IC)

Authorization for Use or Disclosure of Health Information Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form E Attachment E Authorization for Use or Disclosure of Health Information Form FINALCICP Authorization Form 2020.docx Yes Yes Fillable Fileable
Instruction 2 CICP Authorization Form Instructions.doc Yes No Paper Only

Health Consumer Health and Safety

 

100 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 100 0 0 0 0 100
Annual IC Time Burden (Hours) 200 0 0 0 0 200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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