IHS- 917, Request for Correction/Amendment of Protected Health Information

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0030 can be found here:

Documents and Forms

Document Name Document Type
Form 917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction
917 Request for correction/Amendment of Protected Health Inf IHS-917_508 -2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	IHS- 917, Request for Correction/Amendment of Protected Health Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	917	Request for correction/Amendment of Protected Health Information	IHS-917_508 -2016.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records	FR Citation: 75 FR 1625

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	54	-7,446	7,500
Annual IC Time Burden (Hours)	9	-1,866	1,875
Annual IC Cost Burden (Dollars)	0	0	0

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.