Authorization for Release of Medical Information for Black Lung Benefits

ICR 202401-1240-009

OMB: 1240-0034

Federal Form Document

Forms and Documents

Document Name	Status
Form CM-936 Authorization for Release of Medical Information Form	Modified
Form CM-936 Authorization for Release of Medical Information Form	Modified
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx Supporting Statement A	2024-01-30
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx Supporting Statement A	2024-01-30
Justification CM-936.docx Justification for No Material/Nonsubstantive Change	2024-01-30
Justification CM-936.docx Justification for No Material/Nonsubstantive Change	2024-01-30
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2018-09-27
System of Record Notice-DOL OWCP-2.pdf Supplementary Document	2018-09-27
725.405.pdf Supplementary Document	2006-08-09
725.405.pdf Supplementary Document	2006-08-09
30 USC Sec. 902.pdf Supplementary Document	2006-08-09
30 USC Sec. 902.pdf Supplementary Document	2006-08-09
30 USC Sec. 901.pdf Supplementary Document	2006-08-09
30 USC Sec. 901.pdf Supplementary Document	2006-08-09
30 Chapter 22.pdf Supplementary Document	2006-08-09
30 Chapter 22.pdf Supplementary Document	2006-08-09
DOL-ESA-30.pdf Supplementary Document	2006-08-09
DOL-ESA-30.pdf Supplementary Document	2006-08-09

IC Document Collections

IC ID	Document Title	Status
13694	Authorization for Release of Medical Information Form	Modified
13694	Authorization for Release of Medical Information Form	Modified