IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)

Forms and Documents

Document Name	Status
Form 0917-0030, IHS-810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction	Modified
Form 0917-0030, IHS-917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction	Modified
Form 0917-0030 IHS- 913, Request for Accounting of Disclosures Form and Instruction	Modified
Form 0917-0030-IHS-912- IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction	Modified
Form 0917-0030, IHS-912 IHS-912-1, Request for Restriction(s) Form and Instruction	Modified
IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records.pdf Supplementary Document	2013-01-18
OMB_No._0917-0030_Supporting_Statement_FINAL_1-10-13[2].doc Supporting Statement A	2013-01-14

IC Document Collections

IC ID	Document Title	Status
6589	IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction	Modified
191427	IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction	Modified
191426	IHS- 913, Request for Accounting of Disclosures Form and Instruction	Modified
191425	IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction	Modified
191424	IHS-912-1, Request for Restriction(s) Form and Instruction	Modified

ICR Details

OMB Control No: 0917-0030	ICR Reference No: 201301-0917-002
Status: Historical Active	Previous ICR Reference No: 200911-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No: 17299
Title: IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/01/2013
	Date Received in OIRA: 01/22/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved	03/31/2013
Responses	542,500	0	542,500
Time Burden (Hours)	174,375	0	174,375
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request for an extension without a revision of a previously approved collection which is due to expire January 31, 2013. This collection of information is made necessary by the Department of Health and Human Services Rule entitled Standards for Privacy of Individually Identifiable Health Information (A Privacy Rule) (45 CFR Parts 160 and 164). The Privacy Rule implements the privacy requirements of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 and creates national standards that protect patient health information and gives our patients access to their health information.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 264 Name of Law: Health Insurance Portability and Accountability Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 60129	10/02/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 2412	01/11/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
IHS-810, Authorization for Use or Disclosure of Protected Health Information	0917-0030, IHS-810	Authorization for Use or Disclosure of Protected Health Information
IHS-912-1, Request for Restriction(s)	0917-0030, IHS-912-1	Request for Restrictions(s)
IHS-912-2, Request for Revocation of Restriction(s)	0917-0030-IHS-912-2	Request for Revocation of Restriction(s)
IHS- 913, Request for Accounting of Disclosures	0917-0030	Request for Accounting Disclosures
IHS- 917, Request for Correction/Amendment of Protected Health Information	0917-0030, IHS-917	Request for Correction/Amendment of Protected Health Information

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	542,500	542,500	0	0	0	0
Annual Time Burden (Hours)	174,375	174,375	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,260,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/22/2013

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