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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.