Information Collection

Authorization for Use or Disclosure of Health Information Form

IC 208416 under ICR 202603-0915-003 · OMB 0915-0334.

Documents and Forms

Document Name Document Type
Form 2 CICP Authorization Form Authorization for Use or Disclosure of Health Information Form Form
Form 2 CICP Authorization Form Authorization for Use or Disclosure of Health Information Form Form
2 CICP Authorization Form CICP Authorization Form.pdf Form
2 CICP Authorization Form CICP Authorization Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization for Use or Disclosure of Health Information Form	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	CICP Authorization Form	CICP Authorization Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: CICP System of Records Notice	FR Citation: 84 FR 28829

Number of Respondents: 360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	360	260	100
Annual IC Time Burden (Hours)	720	520	200
Annual IC Cost Burden (Dollars)	0	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.

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