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IMPORTANT! Revised Form CM-936 - Authorization for Release of Medical Information

Beginning January 20, the Division of Coal Mine Workers’ Compensation (DCMWC) will be *exclusively* using the newly updated CM-936 (Authorization for Release of Medical Information) [ https://www.dol.gov/sites/dolgov/files/owcp/regs/compliance/cm-936.pdf ] form to collect ALL medical information requests.

Executive Order 14058 [ https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.federalregister.gov%2Fdocuments%2F2021%2F12%2F16%2F2021-27380%2Ftransforming-federal-customer-experience-and-service-delivery-to-rebuild-trust-in-government&data=05%7C02%7CTeague.Tracey%40DOL.gov%7C8894214ebe8a4152ea0308dd3677a4b0%7C75a6305472044e0c9126adab971d4aca%7C0%7C0%7C638726609683203696%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=0%2FVb9MDa2E2BBe0SOpcrc8ZzFAIkLyEkZKsGwjAj2ko%3D&reserved=0 ], Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government, signed in December 2021, directed agencies to examine customer service practices and make improvements. DCMWC reviewed our forms and found the information collected on the CM-934 questionnaire to be an unnecessary burden on the public. We determined that it would be more user friendly to combine all medical information requests into one form (CM-936) to help streamline claim processing while still collecting the information needed to develop and adjudicate claims.  

*What is new about the CM-936:*

The revised form now accommodates medical releases from any type of medical facility, not just hospitals. Consequently, all references to “Hospitals” or “hospitalization” have been updated to “Facility or Clinic”, encompassing doctor’s offices, medical clinics, urgent care facilities, and hospitals. Additionally, we updated the initial blocks to assist in recognizing the person completing the form. The form has also been modified to capture information for multiple medical facilities - designed to collect the same type of information for up to four different providers utilizing the same signature authority.

Please ensure that you are using the latest versions of all DCMWC’s forms [ https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms ].

If you have questions, please contact your Claims Examiner or call 1-800-347-2502.

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