ML23254A225

OMB 3150-XXXX New NRC Form 995, Authorization for Use or Disclosure of Protected Health Information

ML23254A225
Person / Time
Issue date:	06/04/2024
From:	NRC/OCIO, NRC/OGC
To:
References
OMB 3150-XXXX
Download: ML23254A225 (1)

Text

NRC FORM 995 (MM-DD-YYYY)

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION U.S. NUCLEAR REGULATORY COMMISSION Last Name, First Name, and Middle Initial Date of Birth Email Section 1. Whose information will be disclosed?

NRC FORM 995 (MM-DD-YYYY)

Page 1 of 1 Signature and Date - Employee Signature and Date - Representative EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-XXXX Estimated burden per response to comply with this voluntary information collection request: 75 minutes. This form is used by NRC to obtain medical information related to your request for Leave Bank, Family Medical Leave Act (FMLA) Leave, Reasonable Accommodation (RA), Disability certification, and/or certification of health care coverage. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-XXXX), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

Program Office (Office/Division/Branch - Acronyms)

Work Telephone Number (Enter 10 numbers)

Section 2. I hereby voluntarily authorize the disclosure of health record information about the individual named above. I am:

The individual named above.

A representative on behalf of the individual named above.

Section 3. I authorize disclosure FROM my provider:

Name Address Telephone Number Facsimile Number To the following medical reviewer:

Name Address Telephone Number Facsimile Number Email Section 4. Purpose for disclosure (check the applicable box):

Leave Bank/

FMLA Disability/

Reasonable Accommodation Health Care Coverage (Self or dependent)

Other:

Section 5. Information to be disclosed (check the applicable box):

All of my medical-related information Only medical information related to Only medical information from:

Start Date:

End Date:

Section 6. Sensitive Health Information (check the applicable box(es)):

Alcohol/Drug Abuse Treatment/Referral HIV Status/AIDS and related treatment Sexually Transmitted Diseases Mental Health (other than Psychotherapy Notes)

Not Appliable Section 7. Acknowledgement:

This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. I understand that I may revoke this authorization by submitting a revocation notice in writing at any time, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate six months from the date of my signature unless a different expiration date is specified here. Specified Expiration Date:

For representative signature, use the following signature area:

Being a minor. The individual named is years old and considered a minor under the law.

The individual is unable to sign due to (check one):

Being incapacitated. The individual named is incapacitated due to:

Other:

Relationship to Individual:

SIGN SIGN

NRC FORM 995 (MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (Continued)

About this Form:

The use of this form is voluntary. This form is used by NRC to obtain medical information related to your request for Leave Bank, Family Medical Leave Act (FMLA) Leave, Reasonable Accommodation (RA), Disability certification, and/or certification of health care coverage. By providing the information requested on this form, the NRC's medical reviewing body will be able to obtain information from your medical provider in order to provide NRC a recommendation regarding your request. The NRC's medical reviewing body will provide this recommendation to the appropriate NRC point of contact who will coordinate a decision on your request. The medical reviewing body will only share information related to your request.

Information collected in this form is confidential and protected by The Privacy Act of 1974 and the Genetic Information Nondiscrimination Act of 2008.

Instructions for Completing this Form:

Section 1. Print the name of the individual releasing their medical information along with their date of birth. Provide the individual's program office within NRC and a contact phone number.

Section 2. Indicate whether the individual completing this form is doing so for themselves or on behalf of another individual.

Section 3. Print the name, address and contact information (phone, fax, email address) of the person/organization/

facility releasing the information. Also provide the name, address and contact information of the person/organization/

facility that will receive the information.

NOTE: The agency will pre-populate the TO field with the information of the NRC's medical reviewing body.

Section 4. Select the reason for the information disclosure. If the reason is not listed, please select `other' and write the reason in the space provided.

Section 5. Circumscribe the information to be disclosed. You may authorize disclosure from your entire medical record, specify only records related to a particular medical issue (injury, illness, disability, treatment, etc.), specify only records related to a time period of your medical history, or you may articulate how you would like the information disclosed to be limited.

Section 6. If the information to be released contains information in one or more of the sensitive health areas identified, check all that apply.

Section 7. Sign and Date. This authorization is incomplete without signature AND date. If a different disclosure authorization expiration date is desired, specify a new date. If authorization is made through a representative, please utilize the appropriate justification and signature line(s).

Instructions for the Disclosing Medical Provider:

The individual named in this form has notified The Nuclear Regulatory Commission (NRC) of a request for Leave Bank, Family Medical Leave Act (FMLA) Leave, Reasonable Accommodation (RA), Disability certification, and/or certification of health care coverage. The medical reviewer named is seeking medical information regarding this individual from you in order to reach a decision on their request and will contact you regarding the information needed. Your response should be your best estimate based upon your medical knowledge, experience, and examination of the individual. Be as specific as possible and limit your response to the circumstances of the individual's request.

You are hereby authorized to furnish information from the record of the individual named.

PRIVACY ACT STATEMENT FOR NRC FORM 995

1. PRIVACY ACT STATEMENT NRC FORM 995 - INFORMATION RELATED TO PAYROLL ACCOUNTING RECORDS

2. PRIVACY ACT STATEMENT NRC FORM 995 - INFORMATION RELATED TO EMPLOYEE HEALTH CENTER RECORDS

3. PRIVACY ACT STATEMENT NRC FORM 995 - INFORMATION RELATED TO REASONABLE ACCOMMODATION RECORDS

2. PRINCIPAL PURPOSE(S): The purpose for requesting this information is to permit contact with an individual's health care provider in order to confirm and/or clarify medical information relative to an individual's request for Leave Bank, Family Medical Leave Act (FMLA) leave, and/or certification of health care coverage.

1. AUTHORITY: 26 CFR 31.6011(b)-2, 31.6109-1; 5 U.S.C. 6334; 5 U.S.C. part III, subpart D; 31 U.S.C. 716. 31 U.S.C., subtitle III, chapters 35 and 37; Executive Order (E.O.) 9397, as amended by E.O. 13478; Social Security Number Fraud Prevention Act of 2017, 42 U.S.C. 405 note.

Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 995 related to leave bank requests, FMLA leave requests, or health care coverage benefits. This information is maintained as part of the following system of records, designated as NRC-21 (Payroll Accounting Records). This system is described in the most recent Federal Register publication of the NRC's System of Records Notice for this system, which can be accessed from the agency's public web site at: https://www.nrc.gov/reading-rm/foia/privacy-systems.html.

PRIVACY ACT STATEMENT FOR NRC FORM 995, AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION RELATED TO PAYROLL ACCOUNTING RECORDS

3. ROUTINE USE(S): In accordance with an interagency agreement the NRC may disclose records in the NRC-21 system of records to the DOI/IBC FPPS in order to affect all financial transactions on behalf of the NRC related to employee pay. Specifically, the DOI/IBC's FPPS may affect employee pay or deposit funds on behalf of NRC employees, and/or it may withhold, collect or offset funds from employee salaries as required by law or as necessary to correct overpayment or amounts due. NRC may also disclose information contained in the NRC-21 system of records without the consent of the subject individual if the disclosure is compatible with the purpose for which the record was collected under the following routine uses; or, where determined to be appropriate and necessary, the NRC may authorize DOI/IBC to make the disclosure:

a. For transmittal of data to U.S. Treasury to effect issuance of paychecks to employees and consultants and distribution of pay according to employee directions for savings bonds, allotments, financial institutions, and other authorized purposes including the withholding and reporting of Thrift Savings Plan deductions to the Department of Agriculture's National Finance Center;

b. For reporting tax withholding to Internal Revenue Service and appropriate state and local taxing authorities;

c. For FICA and Medicare deductions to the Social Security Administration;

d. For dues deductions to labor unions;

e. For withholding for health insurance to the insurance carriers by the Office of Personnel Management;

f. For charity contribution deductions to agents of charitable institutions;

g. For annual W-2 statements to taxing authorities and the individual;

h. For transmittal to the Office of Management and Budget for financial reporting;

i. For withholding and reporting of retirement, tax levies, bankruptcies, garnishments, court orders, re-employed annuitants, and life insurance information to the Office of Personnel Management;

j. For transmittal of information to State agencies for unemployment purposes;

k. For transmittal to the Office of Child Support Enforcement, Administration for Children and Families, Department of Health and Human Services Federal Parent Locator System and Federal Tax Offset System for use in locating individuals and identifying their income sources to establish paternity, establish and modify orders of support, and for enforcement action;

l. For transmittal to the Office of Child Support Enforcement for release to the Social Security Administration for verifying social security numbers in connection with the operation of the Federal Parent Locator System by the Office of Child Support Enforcement;

m. For transmittal to the Office of Child Support Enforcement for release to the Department of Treasury for the purpose of administering the Earned Income Tax Credit Program (Section 32, Internal Revenue Code of 1986) and verifying a claim with respect to employment in a tax return;

n. To the National Archives and Records Administration or to the General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906;

o. Time and labor data are used by the NRC as a project management tool in various management records and reports (i.e. work performed, work load projections, scheduling, project assignments, budget), and for identifying reimbursable and fee billable work performed by the NRC;

p. A record from this system of records which indicates a violation of civil or criminal law, regulation or order may be referred as a routine use to a Federal, State, local or foreign agency that has authority to investigate, enforce, implement or prosecute such laws. Further, a record from this system of records may be disclosed for civil or criminal law or regulatory enforcement purposes to another agency in response to a written request from that agency's head or an official who has been delegated such authority;

q. A record from this system of records may be disclosed as a routine use to a Federal, State, local, or foreign agency to obtain information relevant to an NRC decision concerning hiring or retaining an employee, letting a contract, or issuing a security clearance, license, grant or other benefit;

r. A record from this system of records may be disclosed as a routine use to a Federal, State, local, or foreign agency requesting a record that is relevant and necessary to its decision on a matter of hiring or retaining an employee, issuing a security clearance, reporting an investigation of an employee, letting a contract, or issuing a license, grant, or other benefit;

s. A record from this system of records may be disclosed as a routine use in the course of discovery; in presenting evidence to a court, magistrate, administrative tribunal, or grand jury or pursuant to a qualifying order from any of those; in alternative dispute resolution proceedings, such as arbitration or mediation; or in the course of settlement negotiations;

t. A record from this system of records may be disclosed as a routine use to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual;

u. A record from this system of records may be disclosed as a routine use to NRC paid experts or consultants, and those under contract with the NRC on a "need-to-know" basis for a purpose within the scope of the pertinent NRC task. This access will be granted to an NRC contractor or employee of such contractor by a system manager only after satisfactory justification has been provided to the system manager;

v. A record from this system of records may be disclosed as a routine use to appropriate agencies, entities, and persons when (1) NRC suspects or has confirmed that there has been a breach of the system of records, (2) NRC has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, NRC (including its information systems, programs, and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with NRC efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm; and

w. A record from this system of records may be disclosed as a routine use to another Federal agency or Federal entity, when the NRC determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Providing this information is voluntary. However, not providing this information may result in the agency being unable to make a fully informed determination on your request, which could potentially result in denial of the request.

5. SYSTEM MANAGER(S) AND ADDRESS: Chief, Financial Services and Operations Branch, Division of the Comptroller, Office of the Chief Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

PRIVACY ACT STATEMENT FOR NRC FORM 995, AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION RELATED TO EMPLOYEE HEALTH CENTER RECORDS Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 995 to authorize disclosure of records maintained by the Employee Health Center. This information is maintained as part of the following system of records, designated as NRC-43 (Employee Health Center Records). This system is described in the most recent Federal Register publication of the NRC's System of Records Notice for this system, which can be accessed from the agency's public web site at: https://www.nrc.gov/reading-rm/foia/privacy-systems.html.

1. AUTHORITY: U.S.C. 7901; Executive Order 9397, as amended by E.O. 13478.

2. PRINCIPAL PURPOSE(S): The purpose for requesting this information is to permit contact with an individual's health care provider in order to confirm and/or clarify medical information relative to an individual's request for Leave Bank, Family Medical Leave Act (FMLA) leave, and/or certification of health care coverage.

3. ROUTINE USE(S): The NRC may disclose information contained in this system of records without the consent of the subject individual if the disclosure is compatible with the purpose for which the record was collected under the following routine uses:

a. To refer information required by applicable law to be disclosed to a Federal, State, or local public health service agency concerning individuals who have contracted certain communicable diseases or conditions in an effort to prevent further outbreak of the disease or condition;

b. To disclose information to the appropriate Federal, State, or local agency responsible for investigation of an accident, disease, medical condition, or injury as required by pertinent legal authority;

c. To disclose information to the Office of Workers' Compensation Programs in connection with a claim for benefits filed by an employee;

d. To Health Center staff and medical personnel under a contract or agreement with NRC who need the information in order to schedule, conduct, evaluate, or follow up on physical examinations, tests, emergency treatments, or other medical and health care services;

e. To refer information to private physicians designated by the individual when requested in writing;

f. To the National Archives and Records Administration or to the General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906;

g. A record from this system of records which indicates a violation of civil or criminal law, regulation or order may be referred as a routine use to a Federal, State, local or foreign agency that has authority to investigate, enforce, implement or prosecute such laws. Further, a record from this system of records may be disclosed for civil or criminal law or regulatory enforcement purposes to another agency in response to a written request from that agency's head or an official who has been delegated such authority;

h. A record from this system of records may be disclosed as a routine use to a Federal, State, local, or foreign agency to obtain information relevant to an NRC decision concerning hiring or retaining an employee, letting a contract, or issuing a security clearance, license, grant or other benefit;

i. For withholding and reporting of retirement, tax levies, bankruptcies, garnishments, court orders, re-employed annuitants, and life insurance information to the Office of Personnel Management;

j. A record from this system of records may be disclosed as a routine use in the course of discovery; in presenting evidence to a court, magistrate, administrative tribunal, or grand jury or pursuant to a qualifying order from any of those; in alternative dispute resolution proceedings, such as arbitration or mediation; or in the course of settlement negotiations;

k. A record from this system of records may be disclosed as a routine use to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual;

l. A record from this system of records may be disclosed as a routine use to NRC-paid experts or consultants, and those under contract with the NRC on a "need-to-know" basis for a purpose within the scope of the pertinent NRC task. This access will be granted to an NRC contractor or employee of such contractor by a system manager only after satisfactory justification has been provided to the system manager;

m. A record from this system of records may be disclosed as a routine use to appropriate agencies, entities, and persons when (1) NRC suspects or has confirmed that there has been a breach of the system of records, (2) NRC has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, NRC (including its information systems, programs, and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with NRC efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm; and

n. A record from this system of records may be disclosed as a routine use to another Federal agency or Federal entity, when the NRC determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION:

Providing this information is voluntary. However, not providing this information may result in the agency being unable to make a fully informed determination on your reasonable accommodation request, which could potentially result in denial of the request.

5. SYSTEM MANAGER(S) AND ADDRESS: Technical Assistance Project Manager, Office of Chief Human Capital Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

PRIVACY ACT STATEMENT FOR NRC FORM 995, AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION RELATED TO REASONABLE ACCOMMODATION RECORDS Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 995 related to Reasonable Accommodation Requests. This information is maintained as part of the following system of records, designated as NRC-11 (Reasonable Accommodation Records). This system is described in the most recent Federal Register publication of the NRC's System of Records Notice for this system, which can be accessed from the agency's public web site at: https://www.nrc.

gov/reading-rm/foia/privacy-systems.html.

1. AUTHORITY: Executive Order (E.O.) 13164; E.O. 9397, as amended by E.O. 13478; Social Security Number Fraud Prevention Act of 2017, 42 U.S.C. 405 note.

2. PRINCIPAL PURPOSE(S): The purpose for requesting this information is to permit contact with an individual's health care provider in order to confirm and/or clarify medical information relative to an individual's request for Reasonable Accommodation (RA).

3. ROUTINE USE(S): The NRC may disclose information contained in this system of records without the consent of the subject individual if the disclosure is compatible with the purpose for which the record was collected under the following routine uses;

a. A record from this system of records may be disclosed as a routine use to a prospective employer of a Government employee. Upon transfer of the employee to another Federal agency, the information may be transferred to such agency; directions for savings bonds, allotments, financial institutions, and other authorized purposes including the withholding and reporting of Thrift Savings Plan deductions to the Department of Agriculture's National Finance Center;

b. A record from this system of records may be disclosed as a routine use to provide information to the OPM and/or MSPB for review, audit, or reporting purposes;

c. A record from this system of records which indicates a violation of civil or criminal law, regulation or order may be referred as a routine use to a Federal, State, local or foreign agency that has authority to investigate, enforce, implement or prosecute such laws. Further, a record from this system of records may be disclosed for civil or criminal law or regulatory enforcement purposes to another agency in response to a written request from that agency's head or an official who has been delegated such authority;

d. A record from this system of records may be disclosed as a routine use to a Federal, State, local, or foreign agency to obtain information relevant to an NRC decision concerning hiring or retaining an employee, letting a contract, or issuing a security clearance, license, grant or other benefit;

e. A record from this system of records may be disclosed as a routine use to a Federal, State, local, or foreign agency requesting a record that is relevant and necessary to its decision on a matter of hiring or retaining an employee, issuing a security clearance, reporting an investigation of an employee, letting a contract, or issuing a license, grant, or other benefit;

f. A record from this system of records may be disclosed as a routine use in the course of discovery; in presenting evidence to a court, magistrate, administrative tribunal, or grand jury or pursuant to a qualifying order from any of those; in alternative dispute resolution proceedings, such as arbitration or mediation; or in the course of settlement negotiations;

g. A record from this system of records may be disclosed as a routine use to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual;

h. A record from this system of records may be disclosed as a routine use to NRC-paid experts or consultants, and those under contract with the NRC on a "need-to-know" basis for a purpose within the scope of the pertinent NRC task. This access will be granted to an NRC contractor or employee of such contractor by a system manager only after satisfactory justification has been provided to the system manager;

i. A record from this system of records may be disclosed as a routine use to appropriate agencies, entities, and persons when (1) NRC suspects or has confirmed that there has been a breach of the system of records, (2) NRC has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, NRC (including its information systems, programs, and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with NRC efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm; and

j. A record from this system of records may be disclosed as a routine use to another Federal agency or Federal entity, when the NRC determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Providing this information is voluntary. However, not providing this information may result in the agency being unable to make a fully informed determination on your reasonable accommodation request, which could potentially result in denial of the request.

5. SYSTEM MANAGER(S) AND ADDRESS: Human Resources Specialist (RA) and Branch Chief, Policy, Labor and Employee Relations Branch, Associate Director for Human Resources Operations and Policy, Office of Chief Human Capital Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.