Information Collection

Release of Information (HIPPA) (M/FF/CW)

IC 243423 under ICR 202008-0920-005 · OMB 0920-1331.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1331 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Release of Information (HIPPA) (M/FF/CW)	Form
0920 Release of Information (HIPAA Privacy Authorization Form Appendix N ROI.docx	Form
0920 Release of Information (HIPAA Privacy Authorization Form Appendix N ROI.docx	Form

IC Title:

Release of Information (HIPPA) (M/FF/CW)

Agency IC Tracking Number:

0920-20HO

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	0920	Release of Information (HIPAA Privacy Authorization Form)	Appendix N ROI.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	1	1
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.