Information Collection

IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)

IC 6589 under ICR 200608-0917-002 · OMB 0917-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS-917 IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)	Form and Instruction
IHS-810 Auth. use/disclosure hlth info. IHS-810.pdf	Form and Instruction
IHS912-1 Request for Restrictions IHS-912-1.pdf	Form and Instruction
IHS912-2 Request for Revocation of Restr. IHS-912-2.pdf	Form and Instruction
IHS-913 Req. for an Acct. of Disclosures IHS-913.pdf	Form and Instruction
IHS-917 Request for Correction IHS-917.pdf	Form and Instruction

IC Title:

IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	IHS-917	Request for Correction	IHS-917.pdf	Yes	Yes	Fillable Printable
Form and Instruction	IHS-810	Auth. use/disclosure hlth info.	IHS-810.pdf	Yes	Yes	Fillable Printable
Form and Instruction	IHS912-1	Request for Restrictions	IHS-912-1.pdf	Yes	Yes	Fillable Printable
Form and Instruction	IHS912-2	Request for Revocation of Restr.	IHS-912-2.pdf	Yes	Yes	Fillable Printable
Form and Instruction	IHS-913	Req. for an Acct. of Disclosures	IHS-913.pdf	Yes	Yes	Fillable Printable

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 542,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	542,500	0	542,500
Annual IC Time Burden (Hours)	5,425	-168,950	174,375
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.