HIPAA Authorization [Control Patient Participants]

Using Real-time Prescription and Insurance Claims Data to Support the HIV Care Continuum

Documents and Forms

Document Name Document Type
HIPAA Authorization [Control Patient Participants] Form
HIPAA Authorization Att 8d_HIPPA authorization.docx Form
HIPAA Authorization Att 8d_HIPPA authorization.docx Form

Information Collection (IC) Details

IC Title:	HIPAA Authorization [Control Patient Participants]	Agency IC Tracking Number:

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	n/a	HIPAA Authorization	Att 8d_HIPPA authorization.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems:(SORN) 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 167	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	167	167
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	302	302

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.