Forms, Policies & Procedures

The Indian Health Service's (IHS) Learn, Train & Protect Health Insurance Portability and Accountability Act (HIPAA) training program includes a number of forms, policies and procedures that you must use and follow to comply with HIPAA standards. Each of the files below are in .pdf format and can be downloaded and read using Adobe Acrobat® Reader®. If you do not have Adobe Acrobat® Reader® on your computer, you may download it from the bottom of the left menu.

Notice of Privacy Practices

• IHS NOTICE OF PRIVACY PRACTICES (2007) COLORIZED PAMPHLET [PDF-561KB]

Forms

• Form IHS 810 - Authorization for Use and Disclosure of Health Information [PDF-305]
• Form IHS 912-1 Request for Restrictions [PDF-252]
• Form IHS 912-2 Request for Revocation of Restrictions (Fillable) [PDF-249]
• Form IHS 913 - Request for an Accounting of Disclosures [PDF-254]
• Form IHS 917 - Request for Correction/Amendment of Protected Health Information [PDF-277]
• Form IHS 963 - Request for Confidential Communication by Alternate Means or to an Alternate Location [PDF-60]

Policies and Procedures (P&P)

• IHM Part 2, Chapter 7
  Transmittal Notice-Table of Contents-Introduction

• IHM Exhibit 2-7-A
  P&P on Patients' Rights to Access, Inspect and Obtain a Copy of Their Protected Health Information

• IHM Exhibit 2-7-B
  P&P for Matters Related to Accounting of Disclosures of Protected Health Information

• IHM Exhibit 2-7-C
  P&P for the Transmittal of Confidential Communication by Alternate Means or to an Alternate Location

• IHM Exhibit 2-7-D
  P&P for Use or Disclosure of Health Information Pursuant to Authorization or Valid Written Request

• IHM Exhibit 2-7-E
  P&P on Requests for Correction/Amendment of Protected Health Information

• IHM Exhibit 2-7-F
  P&P for De-Identification of Protected Health Information and Subsequent Re-Identification

• IHM Exhibit 2-7-G
  P&P for Use and Disclosure for Directory Purposes

  " IHM Exhibit 2-7-H
  P&P on the Use and Disclosure of Protected Health Information during a Disaster and for Disaster Relief Purposes

• IHM Exhibit 2-7-I
  P&P for Sending and Receiving Protected Health Information by Facsimile

• IHM Exhibit 2-7-J
  P&P for Creating a Limited Data Set

• Data Use Agreement [PDF-3.9KB]

• IHM Exhibit 2-7-K
  P&P for Limiting the Use or Disclosure of and Requests for Protected Health Information to the Minimum Necessary

• IHM Exhibit 2-7-L
  P&P for Providing Indian Health Service Notice of Privacy Practices

• IHS Notice of Privacy Practices (IHM Exhibit 2-7-L)

• IHM Exhibit 2-7-M
  P&P on Uses and Disclosures of Protected Health Information for Involvement in the Patient's Care and for Notification Purposes

• IHM Exhibit 2-7-N
  P&P for Maintenance, Use and Disclosure of Psychotherapy Notes

• IHM Exhibit 2-7-O
  P&P for Use and Disclosure of Protected Health Information for Research Purposes

• IHM Exhibit 2-7-P
  P&P for Request for Restriction(s) on the Use and Disclosures of Protected Health Information

• IHM Exhibit 2-7-Q
  P&P for Disclosure of Protected Health Information of Un-Emancipated Minors

• IHM Exhibit 2-7-R
  P&P for Verification of Identity Prior to Disclosure of Protected Health Information

• IHM Exhibit 2-7-S
  P&P for the Use and Disclosure of Protected Health Information for Emancipated Minors and Adults with Personal Representatives or Legal Guardians

• IHM Exhibit 2-7-T
  P&P for the Disclosure of Protected Health Information to Law Enforcement Officials