Authorization For Release Of Medical Information For Black Lung Benefits

NON- SUBSTANTIVE CHANGE REQUEST FOR THE AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FOR BLACK LUNG BENEFITS

OMB CONTROL NO. 1240-0034 (January 2024)

DCMWC is requesting a non-substantive change to the approved collection of information contained in the “Authorization for Release of Medical Information for Black Lung Benefits” to update the URL of the coal mine portal, add our toll-free telephone number, and change the suite number of DCMWC’s mailing address in the CM-936 Form.

DCMWC seeks to revise the approved CM-936 as follows:

• Two Filling Options:

1.To file electronically, submit completed form to the COAL Mine Portal: https://coalmine.dol.gov

2. To file by mail, submit completed form to:

OWCP/DCMWC/CMR Correspondence

PO Box 8307

London, KY 40742-8307

For Further information call TOLL FREE: 1-800-347-2502

• Under Public Burden Statement change address to 200 Constitution Avenue, N.W., Suite C3520-DCMWC, Washington, D.C. 20210

This change request does not affect the burden hours. The burden hours remain the same.

The revised form is attached to this change request.