Authorization for Use or Disclosure of Health Information Form

Countermeasures Injury Compensation Program (CICP)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.