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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form IHS-810 Authorization for Use or Disclosure of Protected Health Information	Form and Instruction	Modified	Available
Form IHS-917 Request for Correction/Amendment of Protected Health Information	Form and Instruction	New	Available
Form IHS-913 Request for Accounting of Disclosures	Form and Instruction	New	Available
Form IHS-912-2 Request for Revocation of Restriction(s)	Form	New	Available
Form IHS-912-1 Request for Restriction(s)	Form	New	Available
30DAYIHSFORMS 11-20-09.pdf	Supplementary Document	Uploaded 2009-11-25	Available
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	Supplementary Document	Uploaded 2009-11-12	Available
30DAYIHSFORMS 11-20-09.pdf	Supplementary Document	Uploaded 2009-11-25	Available
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	Supplementary Document	Uploaded 2009-11-12	Available
30DAYIHSFORMS 11-20-09.pdf	Supplementary Document	Uploaded 2009-11-25	Available
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	Supplementary Document	Uploaded 2009-11-12	Available
30DAYIHSFORMS 11-20-09.pdf	Supplementary Document	Uploaded 2009-11-25	Available
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	Supplementary Document	Uploaded 2009-11-12	Available
30DAYIHSFORMS 11-20-09.pdf	Supplementary Document	Uploaded 2009-11-25	Available
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	Supplementary Document	Uploaded 2009-11-12	Available
2009 Supporting Statement (OMB) on IHS HIPAA Forms_FRN6-24-09(rev 11_25_09 bzg)[1][1].doc	Supporting Statement A	Uploaded 2009-11-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6589	IHS Form 810	Form and Instruction	Modified	Authorization for Use or Disclosure of Protected Health Information
191427	Form 917	Form and Instruction	New	Request for Correction/Amendment of Protected Health Information
191426	Form 913	Form and Instruction	New	Request for Accounting of Disclosures
191425	Form IHS-912-2	Form	New	Request for Revocation of Restriction(s)
191424	Form IHS-912-1	Form	New	Request for Restriction(s)

ICR Details

OMB Control No: 0917-0030	ICR Reference No: 200911-0917-001
Status: Historical Active	Previous ICR Reference No: 200608-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/26/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/25/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved	01/31/2010
Responses	542,500	0	542,500
Time Burden (Hours)	174,375	0	5,425
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request for an extension on a previously approved collection which is due to expire November 30, 2009. This collection of information is made necessary by the Department of Health and Human Services Rule entitled Standards for Privacy of Individually Identifiable Health Information (A Privacy Rule) (45 CFR Parts 160 and 164). The Privacy Rule implements the privacy requirements of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 and creates national standards that protect patient health information and gives our patients access to their health information.

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Authorizing Statute(s): Statute at Large: 42 Stat. 1320
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 30095	06/24/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 60264	11/20/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Form 913	IHS-913	Request for Accounting of Disclosures
Form 917	IHS-917	Request for Correction/Amendment of Protected Health Information
Form IHS-912-1	IHS-912-1	Request for Restriction(s)
Form IHS-912-2	IHS-912-2	Request for Revocation of Restriction(s)
IHS Form 810	IHS-810	Authorization for Use or Disclosure of Protected Health Information

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	542,500	542,500	0	0	0	0
Annual Time Burden (Hours)	174,375	5,425	0	0	168,950	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,260,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/25/2009

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