Information Collection

S2S LRP – Authorization to Release Information

IC 211166 under ICR 202004-0915-005 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Document Name Document Type
Form 1 S2S LRP – Authorization to Release Information Form and Instruction
1 FY 2017 NHSC S2S LRP Authorization to Release.docx FY 2017 NHSC S2S LRP Authorization to Release.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	S2S LRP â Authorization to Release Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	FY 2017 NHSC S2S LRP Authorization to Release.docx	FY 2017 NHSC S2S LRP Authorization to Release.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	10	10
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.