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View ESA-OWCP-DCMWC's Form 1215-0057 Online 
| Agency: |
ESA-OWCP-DCMWC |
| Title: |
CM-936, Authorization For Release Of Medical Information (Black Lung Benefits) |
| Form Description: |
CM-936, Authorization For Release Of Medical Information (Black Lung Benefits): The CM-936 is used by claimants who wish to grant permission to DCMWC to request evidence of medical treatment in support of their claims. The form provides the claimant's consent for medical institutions and private physicians to release medical information to DCMWC. |
| OMB Control Number: |
1215-0057 |
| OMB Expiration Date: |
Saturday, October 31, 2009
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