Information Collection

Request for Medical Records

IC 274683 under ICR 202507-0920-012 · OMB 0920-0020.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24IK Request for Medcial Record Request for Medical Records	Form
Form 0920-0020 Medical Records Request Form - revised 15JUL2025 Request for Medical Records	Form
0920-24IK Request for Medcial Record Attachment 27 CWHSP-Request-for-Medical-Records_08152024.pdf	Form
0920-0020 Medical Records Request Form - revised 15JUL2025 CWHSP-Request-for-Medical-Records_No Spirometry.pdf	Form

IC Title:

Agency IC Tracking Number:

0920-0020-24IK

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	0920-24IK				Yes	Yes	Fillable Fileable
Form	0920-0020			N/A	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 %

table that charts list of burden
	Approved	Previously Approved
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

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.

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