Indian Health Service The Federal Health Program for American Indians and Alaska Natives
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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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