Information Collection

Release of Information

IC 247946 under ICR 202512-0920-007 · OMB 0920-1357.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25-0177 Release of Information	Form
Form 0920-25-0177 Release of Information Release of Information	Form
0920-25-0177 Release of Information Att 4b Release of Information.docx	Form
0920-25-0177 Release of Information Att 4b Release of Information.docx	Form

IC Title:

Agency IC Tracking Number:

0920-25--0177

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	0920-25-0177				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	252	252
Annual IC Time Burden (Hours)	2	2
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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