Authorization for Release of Medical Information (Black Lung Benefits)

OMB 1215-0057

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-936 Authorization for Release of Medical Information Form
ss 1215-0057 (CM-936) 7-07-09.doc Supporting Statement A
725.405.pdf Supplementary Document
30 USC Sec. 902.pdf Supplementary Document
30 USC Sec. 901.pdf Supplementary Document
30 Chapter 22.pdf Supplementary Document
DOL-ESA-30.pdf Supplementary Document
DOL-ESA-6.pdf Supplementary Document
Authorization for Release of Medical Information Form