Form IHS-917 Request for Correction

IHS-917 (4/06)

FRONT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED: OMB NO. 0917-0030
Expiration Date: xx/xx/xxxx
See OMB Statement on Reverse.

Indian Health Service

REQUEST FOR CORRECTION/AMENDMENT OF PROTECTED HEALTH INFORMATION
5 U.S.C. 522a(d) and 45 CFR 164.526
PATIENT NAME

DATE OF BIRTH

PATIENT RECORD NUMBER

PATIENT ADDRESS

DATE OF ENTRY TO BE CORRECTED/AMENDED

INFORMATION TO BE CORRECTED/AMENDED

Please explain how the entry is incorrect or incomplete. What should the entry say to be more accurate or complete?
Use additional sheets if needed and attach to this form.

PROOF
IHS will make reasonable efforts to provide the amendment to other persons who IHS knows received the
information in the past and who may have relied, or are likely to rely, on such information in a manner that may be
detrimental to your health care.
I agree to allow IHS to release any amended information to individuals or entities as described above.
Would you like this amendment sent to anyone else who received the information in the past?
Yes

No

If yes, please specify the name and address of the organization(s) or individual(s) below.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
(If Personal Representative, state relationship to patient) or Witness (if signature is thumb print or mark)

DATE

FOR IHS USE ONLY
DATE RECEIVED

AMENDMENT HAS BEEN

Accepted

Denied

IF DENIED, CHECK REASON FOR DENIAL

PHI is not part of the patient’s designated record set
IHS did not create record
Record is not available to the patient for inspection under federal law
Record is accurate and complete
SIGNATURE OF CEO OR DESIGNEE

DATE

COMMENTS OF HEALTHCARE PROVIDER (If applicable)

SIGNATURE OF HEALTHCARE PROVIDER (If applicable)

TITLE

DATE

PSC Graphics (301) 443-1090

EF

IHS-917 (4/06)

BACK

Instructions for Completing IHS Form 917 -Request for Correction/Amendment of Protected Health Information (PHI)
1. Print legibly in all fields using dark permanent ink.
2. Sign and date the request.
3. Submit the completed and signed form to the Chief Executive Officer (CEO).
4. You will receive a photocopy of your completed form, as an acknowledgement of receipt of your request,
no later than 10 business days after IHS receives your request.
5. You will be notified of the acceptance or denial of your request.
6. If your request is accepted, IHS will follow its policy for amendment or correction of health information by
informing you and notifying others. If you are a U.S. citizen or alien lawfully admitted for permanent
residence, IHS is required by law to notify any previous recipient of the record in question of the corrective
action taken, if IHS made an accounting of such disclosure. In addition, regardless of your citizenship
status, subject to your agreement IHS will make reasonable efforts to send any amended or corrected
information to anyone who IHS knows received this information in the past and who may have relied or is
likely to rely on such information to your detriment. IHS will also make reasonable efforts to send the
correction or amendment to those individuals or entities/organizations you identify and who have a need
for the correction or amendment.

PROOF

7. If you are not a U.S. citizen or alien lawfully admitted for permanent residence, and your request is denied,
you may do the following:
a. Submit to the Service Unit CEO a one page written statement disagreeing with the denial and the basis
of such disagreement.
b. If you do not submit a statement of disagreement, you may request that IHS provide this request for
correction or amendment (or summary) and the denial with any future disclosures.
c. IHS has the right to prepare a written rebuttal to any statement of disagreement. You will be provided a
copy of any rebuttal statement. Any written rebuttal prepared by IHS is not subject to correction or
amendment.
8. If you are a U.S. citizen or alien lawfully admitted for permanent residence, you may appeal the refusal to
correct or amend the requested information to the Area Director. In the event your appeal is ultimately
denied, or if you elect not to appeal, you may submit a statement of disagreement or request as described
in 7(a) and 7(b) above. In addition, if your appeal is denied, you may seek judicial review of the decision.
9. If you have a complaint about IHS’ policies and procedures regarding health information, you may file such
a complaint with the Service Unit CEO; Office for Civil Rights; or with the Secretary, Department of Health
and Human Services, Washington, DC 20201.
FOR IHS CEO: Insert Service Unit address, CEO’s name & Title, and Telephone # into area below.

10. This form and subsequent information pertaining to this request will become part of your permanent health
record.
OMB STATEMENT: Public reporting burden for this collection of information is estimated to average 15 minutes per response including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, 801 Thompson Ave., TMP
Suite 450, Rockville, MD 20852, RE: PRA 0917-0030. Please DO NOT SEND this form to this address.