Information Collection

Follow-up to Request for Clinical & Medical Treatment Records

IC 214198 under ICR 202306-3095-005 · OMB 3095-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3095-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NA For 13177 Follow-up to Request for Clinical & Medical Treatment Records	Form and Instruction
Form NA For 13177 Check the Status of a Clinical & Medical & Treatment Records Request Follow-up to Request for Clinical & Medical Treatment Records	Form and Instruction
NA For 13177 Check the Status of a Clinical & Medical & Treatment Rec NA13177_06_2017_3095-0039.pdf www.archives.gov/forms/st-louis/clinical-followup.html	Form and Instruction
NA For 13177 Check the Status of a Clinical & Medical & Treatment Rec NA13177_06_2017_3095-0039.pdf www.archives.gov/forms/st-louis/clinical-followup.html	Form and Instruction
Explanation_June_2023.docx Explanation_June_2023	IC Document
Explanation_June_2023.docx Explanation_June_2023	IC Document

IC Title:

Follow-up to Request for Clinical & Medical Treatment Records

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	NA For 13177	Check the Status of a Clinical & Medical & Treatment Records Request	NA13177_06_2017_3095-0039.pdf	https://www.archives.gov/forms/st-louis/clinical-followup.html	Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Cultural and Historic Preservation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	Previously Approved
Annual Number of Responses for this IC	1	-499	500
Annual IC Time Burden (Hours)	0	-25	25
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Explanation_June_2023	Explanation_June_2023.docx	06/15/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.