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 - 684KB] |
| OMB Number: | 0917-0030 |
| Exp. Date: | 4/30/2016 |
| Created Date: | 4/09 |
| Document: | IHS-963 : Request for Confidential Communication by Alternate Means or Alternate Location [PDF - 290KB] |
| OMB Number: | NA |
| Exp. Date: | NA |
| Created Date: | 4/09 |
| Document: | IHS-912-1 : Request For Restriction(s) [PDF - 538KB] |
| OMB Number: | 0917-0030 |
| Exp. Date: | 4/30/2016 |
| Created Date: | 4/09 |
| Document: | IHS-912-2 : Request For Revocation of Restriction(s) [PDF - 619KB] |
| OMB Number: | 0917-0030 |
| Exp. Date: | 4/30/2016 |
| Created Date: | 4/09 |
| Document: | IHS-913 : Request For An Accounting of Disclosures [PDF - 596KB] |
| OMB Number: | 0917-0030 |
| Exp. Date: | 4/30/2016 |
| Created Date: | 4/09 |
| Document: | IHS-917 : Request for Correction/Amendment of Protected Health Information [PDF - 553KB] |
| OMB Number: | 0917-0030 |
| Exp. Date: | 4/30/2016 |
| Created Date: | 4/09 |
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