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 - 714 KB]
OMB Number: 0917-0030
Exp. Date: 8/31/2019
Created Date: 4/16
Document: IHS-963 : Request for Confidential Communication by Alternate Means or Alternate Location [PDF - 580 KB]
OMB Number: NA
Exp. Date: NA
Created Date: 4/09
Document: IHS-912-1 : Request For Restriction(s) [PDF - 621 KB]
OMB Number: 0917-0030
Exp. Date: 8/31/2019
Created Date: 4/09
Document: IHS-912-2 : Request For Revocation of Restriction(s) [PDF - 648 KB]
OMB Number: 0917-0030
Exp. Date: 8/31/2019
Created Date: 4/09
Document: IHS-913 : Request For An Accounting of Disclosures [PDF - 626 KB]
OMB Number: 0917-0030
Exp. Date: 8/31/2019
Created Date: 4/09
Document: IHS-917 : Request for Correction/Amendment of Protected Health Information [PDF - 667 KB]
OMB Number: 0917-0030
Exp. Date: 8/31/2019
Created Date: 4/09

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