Fillable U.S. Department of Labor Authorization For Release of (Department of Labor)

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U.S. Department of Labor Authorization For Release of (Department of Labor)

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Authorization For Release of Medical
Information (Black Lung Benefits)
U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
OMB No. 1240-0034
Expires: 02-28-2022
1. Miner's First Name M. I. Last Name
3. E-mail Address
5. DOL’s Case ID Number
8. Address
City
State Zip
Phone
4. Miner's Birth Date
Last NameM. I.6. Claimant's First Name 7. Relationship to Miner
Identifying Information for Hospitals
Facility Name(s)
Admission Date(s) Discharge Date(s)
Give any necessary additional identifying data (such as building, clinic, patient number, etc.)
In-patient
Out-patient
City
Street Address
State Zip
Other:
Miner's address at time of hospitalization
CM-936 (Rev. 02-19)
I hereby authorize any physician, hospital, agency, or other organization, including the National Institute of Occupational Safety and Health,
(NIOSH), to disclose to the Office of Workers' Compensation Programs of the U.S. Department of Labor any medical records or other
information about (my) or (the deceased miner's) medical condition for the purpose of providing information related to my claim for benefits
under the Black Lung Benefits Act.
9. Signature of Claimant (or person on his/her behalf)
10. Date (Month, day, year)
TWO FILING OPTIONS:
1. To file electronically, submit completed form to the COAL Mine Portal:
https://eclaimant.dol-esa.gov/bl
2. To file by mail, submit completed form to:
U.S. Department of Labor
OWCP/DCMWC
PO Box 33610
San Antonio, TX 78265
For further information call TOLL FREE: 1-800-638-7072.
2. Last Four Digits of Miner's SSN
Reset
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Privacy Act Statement
The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Collection of this information is authorized
by the Black Lung Benefits Act, 30 U.S.C. 901 et seq., and 20 CFR 725.405. (2) The information in this form will be used to authorize medical
treatment providers to release information about the miner to the Department of Labor pertinent to the black lung claim. (3)While you are not
required to respond, your cooperation is needed to ensure that your claim is given full and proper consideration. Failure to provide the release
of medical documentation may exclude relevant medical information from consideration in the black lung claim. (4) Information may be used by
other agencies or persons handling matters relating, directly or indirectly to this claim, including liable coal mine operators and their insurance
carriers; medical professionals in obtaining medical services or evaluations; contractors providing automated data processing or other services
to the Department of Labor; representatives of the parties to the claim; and federal, state or local agencies. (5) Furnishing all requested
information will facilitate accurate and timely processing of the black lung claim. (6) This information is included in a System of Records, DOL/
OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. The obligation to respond to this collection is voluntary. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers’
Compensation, Room C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS
OFFICE.
Notice
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help
from DCMWC in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will
provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of
adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this
assistance.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
CM-936 Page 2 (Rev. 02-19)
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U.S. Department of Labor Authorization For Release of (Department of Labor)

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Completed 26 January 2021

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