Authorization for Release of Medical Information for Black Lung Benefits

OMB 1240-0034

Address change for CM-936 form. The CM-936 is used to obtain the black lung claimant's authorization for the Division of Coal Mine Workers' Compensation to request medical evidence in support of the black lung claim.

The latest form for Authorization for Release of Medical Information for Black Lung Benefits expires 2022-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-936 Authorization for Release of Medical Information Form
Form CM-936 Authorization for Release of Medical Information Form
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx Supporting Statement A
Supporting Statement - 1240-0034 OCIO -MM Comments 1.7.22 OCIO Response.docx Supporting Statement A
Justification CM-936.docx Justification for No Material/Nonsubstantive Change
Justification CM-936.docx Justification for No Material/Nonsubstantive Change
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
System of Record Notice-DOL OWCP-2.pdf Supplementary Document
725.405.pdf Supplementary Document
725.405.pdf Supplementary Document
30 USC Sec. 902.pdf Supplementary Document
30 USC Sec. 902.pdf Supplementary Document
30 USC Sec. 901.pdf Supplementary Document
30 USC Sec. 901.pdf Supplementary Document
30 Chapter 22.pdf Supplementary Document
30 Chapter 22.pdf Supplementary Document
DOL-ESA-30.pdf Supplementary Document
DOL-ESA-30.pdf Supplementary Document
Authorization for Release of Medical Information Form
Authorization for Release of Medical Information Form

All Historical Document Collections

202401-1240-009 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-31
202111-1240-003 Approved without change	Extension without change of a currently approved collection	2022-01-20
202010-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-23
202003-1240-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-04-12
201809-1240-001 Approved without change	Revision of a currently approved collection	2018-11-30
201602-1240-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-03-14
201505-1240-002 Approved without change	Revision of a currently approved collection	2015-08-18
201207-1240-001 Approved without change	Revision of a currently approved collection	2012-09-14
201003-1240-034 Approved without change	Extension without change of a currently approved collection	2010-03-12