DCS 343 and 344: Specific Authorization for Disclosure of Financial Information and Specific Authorization for Release of Behavioral Health and Related Medical Information

Specific Authorization for Disclosure of Financial Information (DCSA 343) and Specific Authorization for Release of Behavioral Health and Related Medical Information (DCSA 344)

Documents and Forms

Document Name Document Type
Form DCSA 343 DCS 343 and 344: Specific Authorization for Disclosure of Financial Information and Specific Authorization for Release of Behavioral Health and Related Medical Information Form and Instruction
DCSA 343 Specific Authorization for Disclosure of Financial Infor DCSA 343.docx Form and Instruction
DCSA 344 Specific Authorization for Release of Behavioral Health DCSA 344.docx Form and Instruction

Information Collection (IC) Details

IC Title:	DCS 343 and 344: Specific Authorization for Disclosure of Financial Information and Specific Authorization for Release of Behavioral Health and Related Medical Information	Agency IC Tracking Number:	0705

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DCSA 343	Specific Authorization for Disclosure of Financial Information	DCSA 343.docx		Yes	Yes	Fillable Fileable
Form and Instruction	DCSA 344	Specific Authorization for Release of Behavioral Health and Related Medical Information	DCSA 344.docx		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,563	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,563	3,563
Annual IC Time Burden (Hours)	297	297
Annual IC Cost Burden (Dollars)	18,121	18,121

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.