Information Collection

Authorization to Release Information Form

IC 240484 under ICR 202003-0915-001 · OMB 0915-0301.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0301 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10 Authorization to Release Information Form	Form
10 Authorization To Release Information Form Authorization To Release Information FINAL.pdf	Form

IC Title:

Authorization to Release Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	10	Authorization To Release Information Form	Authorization To Release Information FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	40	40
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.