Information Collection Request

Confidentiality of Substance Use Disorder Patient Records

ICR 202511-0945-002 · OMB 0945-0010 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Justification Statement for Non-substantive Change - Part 2 Forms.pdf Justification for No Material/Nonsubstantive Change Uploaded 2025-11-14 Repair queued
Justification Statement for Non-substantive Change - Part 2 Forms.pdf Justification for No Material/Nonsubstantive Change Uploaded 2025-11-14 Missing upstream
Supplemental Document Part 2 Investigative Agency Report Form.pdf Supplementary Document Uploaded 2025-11-14 Available
Supplemental Document Part 2 Investigative Agency Report Form.pdf Supplementary Document Uploaded 2025-11-14 Repair queued
Supplemental Document Part2_Breach_Portal_Questions.pdf Supplementary Document Uploaded 2025-11-14 Available
Supplemental Document Part2_Breach_Portal_Questions.pdf Supplementary Document Uploaded 2025-11-14 Repair queued
3_1_2024 Part 2 Supporting Statement FINAL.docx Supporting Statement A Uploaded 2024-03-01 Repair queued
3_1_2024 Part 2 Supporting Statement FINAL.docx Supporting Statement A Uploaded 2024-03-01 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
264408 Programs Receiving a Complaint Unchanged
264402 Attach consent form with each disclosure (paper records) Unchanged
264401 Attach consent form with each disclosure (electronic records) Unchanged
256946 Reports to the Secretary Unchanged
256945 Right to Request Restrictions Unchanged
256944 Accounting of Disclosures of Part 2 Records Unchanged
256942 Right to Discuss Patient Notice Unchanged
256941 Less than 500 Affected Individuals (investigating and documenting breach) -- affecting <10 Unchanged
256940 Less than 500 Affected Individuals (investigating and documenting breach) -- affecting 10-499 Unchanged
256923 500 or More Affected Individuals (investigating and documenting breach) Unchanged
256921 Notice to Secretary (notice for breaches affecting fewer than 500 individuals) Unchanged
256920 Notice to Secretary (notice for breaches affecting 500 or more individuals) Unchanged
256919 Media Notice - Breach Unchanged
256918 Individual Notice-Substitute Notice (individuals' voluntary burden to call toll-free number for information) Unchanged
256917 Individual Notice-Substitute Notice (staffing toll-free number) Unchanged
256916 Individual Breach Notice-Substitute Notice (posting or publishing) Unchanged
256915 Individual Breach Notice-Written and E-mail Notice (processing and sending) Unchanged
256914 Individual Breach Notice-Written and E-mail Notice (preparing and documenting) Unchanged
256913 Individual Breach Notice-Written and E-mail Notice (drafting) Unchanged
256890 Disclosures for Audit & Evaluation - Paper Unchanged
256889 Disclosures for Audit & Evaluation - Electronic Unchanged
256888 Disclosures for Research - Paper Unchanged
256887 Disclosures for Research - Electronic Unchanged
256886 Documenting Emergency Treatment Disclosures Unchanged
256885 PDMP Reporting Unchanged
256884 Obtaining Consent for TPO Unchanged
256883 Patient Notice - Providing to Patient Unchanged
256881 Breach Notification - Training Unchanged
256880 Training Program Development Unchanged
256879 Notice to Accompany Disclosure - Updating Unchanged
256878 Updating Consent Form Unchanged
256877 Obtaining Consent - Training Unchanged
256862 Requests for Restrictions - Training Unchanged
256861 Accounting of Disclosures - Training Unchanged
256860 Patient Notice - Updating Unchanged
256859 Patient Notice and Right to Discuss - Training Unchanged
256858 Complaint Procedures & Nonretaliation- Training Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2027 03/31/2027 03/31/2027
15,178,340 0 15,178,340
672,667 0 672,667
0 0 0





Reginfo record details
37
table that charts list of burden
IC Title Form No. Form Name
500 or More Affected Individuals (investigating and documenting breach)
Accounting of Disclosures - Training
Accounting of Disclosures of Part 2 Records
Attach consent form with each disclosure (electronic records)
Attach consent form with each disclosure (paper records)
Breach Notification - Training
Complaint Procedures & Nonretaliation- Training
Disclosures for Audit & Evaluation - Electronic
Disclosures for Audit & Evaluation - Paper
Disclosures for Research - Electronic
Disclosures for Research - Paper
Documenting Emergency Treatment Disclosures
Individual Breach Notice-Substitute Notice (posting or publishing)
Individual Breach Notice-Written and E-mail Notice (drafting)
Individual Breach Notice-Written and E-mail Notice (preparing and documenting)
Individual Breach Notice-Written and E-mail Notice (processing and sending)
Individual Notice-Substitute Notice (individuals' voluntary burden to call toll-free number for information)
Individual Notice-Substitute Notice (staffing toll-free number)
Less than 500 Affected Individuals (investigating and documenting breach) -- affecting 10-499
Less than 500 Affected Individuals (investigating and documenting breach) -- affecting <10
Media Notice - Breach
Notice to Accompany Disclosure - Updating
Notice to Secretary (notice for breaches affecting 500 or more individuals)
Notice to Secretary (notice for breaches affecting fewer than 500 individuals)
Obtaining Consent - Training
Obtaining Consent for TPO
PDMP Reporting
Patient Notice - Providing to Patient
Patient Notice - Updating
Patient Notice and Right to Discuss - Training
Programs Receiving a Complaint
Reports to the Secretary
Requests for Restrictions - Training
Right to Discuss Patient Notice
Right to Request Restrictions
Training Program Development
Updating Consent Form

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 15,178,340 15,178,340 0 0 0 0
Annual Time Burden (Hours) 672,667 672,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No