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U.S. Department of Health and Human Services
for Patients

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 - 905 KB]
OMB Number: 0917-0030 Exp. Date: 09/30/2023 Created Date: 4/16
Document: IHS-963 : Request for Confidential Communication by Alternate Means or Alternate Location [PDF - 566 KB]
OMB Number: NA Exp. Date: NA Created Date: 4/09
Document: IHS-912-1 : Request For Restriction(s) [PDF - 802 KB]
OMB Number: 0917-0030 Exp. Date: 09/30/2023 Created Date: 4/09
Document: IHS-912-2 : Request For Revocation of Restriction(s) [PDF - 835 KB]
OMB Number: 0917-0030 Exp. Date: 09/30/2023 Created Date: 4/09
Document: IHS-913 : Request For An Accounting of Disclosures [PDF - 806 KB]
OMB Number: 0917-0030 Exp. Date: 09/30/2023 Created Date: 4/09
Document: IHS-917 : Request for Correction/Amendment of Protected Health Information [PDF - 853 KB]
OMB Number: 0917-0030 Exp. Date: 09/30/2023 Created Date: 4/09
Document: IHS-976 : Purchased/Referred Care Proof of Residency [PDF - 1.2 MB]
OMB Number: 0917-0040 Exp. Date: 03/31/2022 Created Date: 10/2017

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