Information Collection

Request for Medical Records

IC 274683 under ICR 202501-0920-010 · OMB 0920-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0020 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-24IK Request for Medical Records Form
0920-24IK Request for Medcial Record Attachment 27 CWHSP-Request-for-Medical-Records_08152024.pdf Form
0920-24IK Request for Medcial Record Attachment 27 CWHSP-Request-for-Medical-Records_08152024.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Medical Records	Agency IC Tracking Number:	0920-0020-24IK

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-24IK	Request for Medcial Record	Attachment 27 CWHSP-Request-for-Medical-Records_08152024.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 779	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	779	779
Annual IC Time Burden (Hours)	65	65
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.