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. DOL222s Case ID Number 8. Address City State Zip Phone 4. Miner's Birth Date Last Name M. I. 6. Claimant's First Name 7. Relationship to Miner Identifying Information for HospitalsFacility 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: US Department of Labor OWCP/DCMWC/CMR Correspondence PO Box 8307 London, KY 40742-8307 For further information call TOLL FREE: 1-800-638-7072. 2. Last Four Digits of Miner's SSN American LegalNet, Inc. www.FormsWorkFlow.com 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 Workers222 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.240 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.240 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) American LegalNet, Inc. www.FormsWorkFlow.com