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Thursday, February 9, 2012
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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.
 = 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 |
Adobe PDF file size |
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IHS-810
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0917-0030
1/31/2013
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Authorization For Use
or Disclosure of Protected Health Information
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4/09
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419K
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IHS-963
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Request for Confidential Communication by
Alternate Means or Alternate Location
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4/09
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294K
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IHS-912-1
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0917-0030
1/31/2013
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Request For Restriction(s)
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4/09
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315K
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IHS-912-2
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0917-0030
1/31/2013
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Request For Revocation
of Restriction(s)
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4/09
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347K
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IHS-913
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0917-0030
1/31/2013
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Request For An Accounting
of Disclosures
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4/09
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333K
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IHS-917
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0917-0030
1/31/2013
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Request for Correction/Amendment
of Protected Health Information
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4/09
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332K
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