Authorization for Use or Disclosure of Health Information Form

Countermeasures Injury Compensation Program (CICP)

Documents and Forms

Document Name Document Type
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction
2 CICP Authorization Form 03132023 - CICP Authorization Form- OMB 0915-0334.PDF Form and Instruction
2 CICP Authorization Form 03132023 - CICP Authorization Form- OMB 0915-0334.PDF Form and Instruction
1 CICP Authorization Form in Spanish - Redline 10112023 - (23) CICP Authorization Form 2020 in Spanish - REDLINE.docx Form
1 CICP Authorization Form in Spanish - Redline 10112023 - (23) CICP Authorization Form 2020 in Spanish - REDLINE.docx Form
1 CICP Authorization Form Instructions in Spanish - Redlin 10112023 - (24) CICP Authorization Form Instructions in Spanish - REDLINE.docx Form and Instruction
1 CICP Authorization Form Instructions in Spanish - Redlin 10112023 - (24) CICP Authorization Form Instructions in Spanish - REDLINE.docx Form and Instruction

Information Collection (IC) Details

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	CICP Authorization Form	03132023 - CICP Authorization Form- OMB 0915-0334.PDF	Yes	Yes	Fillable Fileable
Form	1	CICP Authorization Form in Spanish - Redline	10112023 - (23) CICP Authorization Form 2020 in Spanish - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	CICP Authorization Form Instructions in Spanish - Redline	10112023 - (24) CICP Authorization Form Instructions in Spanish - REDLINE.docx	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: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	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.