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

OMB 0917-0030

This is a request for an extension without a revision of a previously approved collection which is due to expire August 31, 2019. 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.

The latest form for IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164) expires 2023-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form IHS 810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction
Form IHS-963 IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction
Form IHS-982 IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction
Form IHS- 917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction
Form IHS 913 IHS- 913, Request for Accounting of Disclosures Form and Instruction
Form IHS 912-2 IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction
Form IHS 912-1 IHS-912-1, Request for Restriction(s) Form and Instruction
OMB_No _0917-0030_Supporting_Statement_Final 9.20.23.docx Supporting Statement A
IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction
IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction
IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction
IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction
IHS- 913, Request for Accounting of Disclosures Form and Instruction
IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction
IHS-912-1, Request for Restriction(s) Form and Instruction

All Historical Document Collections

202309-0917-001 Approved without change	Revision of a currently approved collection	2023-09-21
201908-0917-001 Approved without change	Extension without change of a currently approved collection	2019-08-21
201603-0917-001 Approved with change	Extension without change of a currently approved collection	2016-03-28
201301-0917-002 Approved without change	Extension without change of a currently approved collection	2013-01-22
200911-0917-001 Approved without change	Revision of a currently approved collection	2009-11-25
200608-0917-002 Approved without change	Extension without change of a currently approved collection	2006-08-28
200304-0917-001 Approved without change	Extension without change of a currently approved collection	2003-04-10
200303-0917-001 Approved without change	New collection (Request for a new OMB Control Number)	2003-03-21

OMB Details

IHS-810, Authorization for Use or Disclosure of Protected Health Information

Federal Enterprise Architecture: Health - Health Care Services

Form IHS 810

Authorization for Use or Disclosure of Protected Health Information

Fillable Printable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.