Information Collection

Privacy Act Release Authorization Form

IC 181468 under ICR 202404-0915-002 · OMB 0915-0127.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Privacy Act Release Authorization Form	Form and Instruction
2 Privacy Act Release Authorization Form Privacy Act Release Authorization Form.pdf	Form and Instruction
2 Privacy Act Release Authorization Form Privacy Act Release Authorization Form.pdf	Form and Instruction

IC Title:

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:

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	2	Privacy Act Release Authorization Form	Privacy Act Release Authorization Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: The Public Health Service and National Health Service Corps Health Care Provider Records System

FR Citation: 86 FR 28362

Number of Respondents: 303

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	Previously Approved
Annual Number of Responses for this IC	303	303
Annual IC Time Burden (Hours)	30	30
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.