As a result of the current Federal government funding situation, the information on this website may not be up to date or acted upon. Updates regarding government operating status and resumption of normal operations can be found at www.opm.gov . Despite the lapse in appropriations, IHS will continue to provide direct clinical health care services as well as referrals for contracted services that cannot be provided through IHS clinics. For more information on how IHS is impacted, visit: HHS Contingency Plan
Patient Forms
The following is a list of IHS Patient Forms that have been approved by OMB.
Document: | IHS-810 : Authorization For Use or Disclosure of Protected Health Information [PDF - 714 KB] |
OMB Number: | 0917-0030 |
Exp. Date: | 8/31/2019 |
Created Date: | 4/16 |
Document: | IHS-963 : Request for Confidential Communication by Alternate Means or Alternate Location [PDF - 580 KB] |
OMB Number: | NA |
Exp. Date: | NA |
Created Date: | 4/09 |
Document: | IHS-912-1 : Request For Restriction(s) [PDF - 621 KB] |
OMB Number: | 0917-0030 |
Exp. Date: | 8/31/2019 |
Created Date: | 4/09 |
Document: | IHS-912-2 : Request For Revocation of Restriction(s) [PDF - 648 KB] |
OMB Number: | 0917-0030 |
Exp. Date: | 8/31/2019 |
Created Date: | 4/09 |
Document: | IHS-913 : Request For An Accounting of Disclosures [PDF - 626 KB] |
OMB Number: | 0917-0030 |
Exp. Date: | 8/31/2019 |
Created Date: | 4/09 |
Document: | IHS-917 : Request for Correction/Amendment of Protected Health Information [PDF - 667 KB] |
OMB Number: | 0917-0030 |
Exp. Date: | 8/31/2019 |
Created Date: | 4/09 |
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