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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.