Patient Forms
The following is a list of IHS Patient Forms that have been approved by OMB.
Information
If a form does not display, please download, save, and open the file in Adobe Acrobat.
| 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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