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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 - 804 KB]
OMB Number: 0917-0030 Exp. Date: 11/30/2023 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 - 808 KB]
OMB Number: 0917-0030 Exp. Date: 11/30/2023 Created Date: 4/09
Document: IHS-912-2: Request For Revocation of Restriction(s) [PDF - 704 KB]
OMB Number: 0917-0030 Exp. Date: 11/30/2023 Created Date: 4/09
Document: IHS-913: Request For An Accounting of Disclosures [PDF - 681 KB]
OMB Number: 0917-0030 Exp. Date: 11/30/2023 Created Date: 4/09
Document: IHS-917: Request for Correction/Amendment of Protected Health Information [PDF - 776 KB]
OMB Number: 0917-0030 Exp. Date: 11/30/2023 Created Date: 4/09
Document: IHS-976: Purchased/Referred Care Proof of Residency [PDF - 1.2 MB]
OMB Number: 0917-0040 Exp. Date: 06/30/2025 Created Date: 10/2017

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