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Saturday, January 17, 2009
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The following is a list of IHS Public Use Forms. These forms have been
approved by OMB.
Special Note: PDF documents require the Adobe Acrobat Reader plug-in
in your web browser to view. Please visit the I
H S Plug-in page to install the plug-in you require.
 = Microsort Word
document
 = Adobe Acrobat PDF
document
Right click on the appropriate file and select "Save Target As" if you
wish to save the file to your hard drive.
| IHS Form Number |
OMB Number and Expiration Date |
Title |
Form Date |
MS Word file size |
Adobe PDF file size |
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IHS-810
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0917-0030
11/30/2009
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Authorization For Use
or Disclosure of Health Information
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11/06
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69K
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306K
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IHS-843-1A
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0917-0002
01/31/2010
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Order For Health Services
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5/07
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365K
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504K
|
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IHS-963
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Request for Confidential Communication by
Alternate Means or to an Alternate Location
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8/07
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43K
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64K
|
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IHS-912-1
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0917-0030
11/30/2009
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Request For Restriction(s)
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11/06
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45K
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252K
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IHS-912-2
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0917-0030
11/30/2009
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Request For Revocation
of Restriction(s)
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11/06
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43K
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249K
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IHS-913
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0917-0030
11/30/2009
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Request For An Accounting
of Disclosures
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11/06
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50K
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255K
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IHS-917
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0917-0030
11/30/2009
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Request for Correction/Amendment
of Protected Health Information
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11/06
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61K
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278K
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Acrobat
MS Word