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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-843-1A : Order for Health Services [PDF - 235KB]
OMB Number: 0917-0002
Exp. Date: 4/30/2016
Created Date: 6/12
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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