Information Collection

Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form

IC 260334 under ICR 202305-0906-003 · OMB 0906-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0058 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form	Form and Instruction
Form 6 Pediatric Specialty LRP Auth for Disc of Loan Info Form Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form	Form and Instruction
6 Pediatric Specialty LRP Auth for Disc of Loan Info Form PS LRP Auth for Disc of Loan Info Form.docx	Form and Instruction
6 Pediatric Specialty LRP Auth for Disc of Loan Info Form PS LRP Auth for Disc of Loan Info Form.docx	Form and Instruction

IC Title:

Pediatric Specialty LRP Authorization for Disclosure of Loan Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
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.

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