|
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 |
|
IHS-810
|
0917-0030
11/30/2009
|
Authorization For Use
or Disclosure of Health Information
|
11/06
|
69K
|
306K
|
|
IHS-843-1A
|
0917-0002
01/31/2010
|
Order For Health Services
|
5/07
|
365K
|
504K
|
|
IHS-912-1
|
0917-0030
11/30/2009
|
Request For Restriction(s)
|
11/06
|
45K
|
252K
|
|
IHS-912-2
|
0917-0030
11/30/2009
|
Request For Revocation
of Restriction(s)
|
11/06
|
43K
|
249K
|
|
IHS-913
|
0917-0030
11/30/2009
|
Request For An Accounting
of Disclosures
|
11/06
|
50K
|
255K
|
|
IHS-917
|
0917-0030
11/30/2009
|
Request for Correction/Amendment
of Protected Health Information
|
11/06
|
61K
|
278K
|
|
|
Acrobat
MS Word