Information Collection

Authorization for Use or Disclosure of Health Information Form

IC 208416 under ICR 202110-0915-001 · OMB 0915-0334.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2 CICP Authorization Form Instructions.doc	Instruction
2 CICP Authorization Form Instructions.doc	Instruction
CICP Authorization Form Instructions_sp.pdf	Instruction
CICP Authorization Form Instructions_sp.pdf	Instruction
E Attachment E Authorization for Use or Disclosure of Heal FINALCICP Authorization Form 2020.docx	Form
E Attachment E Authorization for Use or Disclosure of Heal FINALCICP Authorization Form 2020.docx	Form
E - Spanish CICP Authorization Form 2020 SPANISH CICP Authorization Form 2020_sp.pdf	Form
E - Spanish CICP Authorization Form 2020 SPANISH CICP Authorization Form 2020_sp.pdf	Form

IC Title:

Authorization for Use or Disclosure of Health Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			2 CICP Authorization Form Instructions.doc	Yes	No	Paper Only
Form	E	Attachment E Authorization for Use or Disclosure of Health Information Form	FINALCICP Authorization Form 2020.docx	Yes	Yes	Fillable Fileable
Instruction			CICP Authorization Form Instructions_sp.pdf	Yes	Yes	Fillable Fileable
Form	E - Spanish	CICP Authorization Form 2020 SPANISH	CICP Authorization Form 2020_sp.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
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.