Form IHS-810 Authorization for Use or Disclosure of Protected Health

IHS-810 (4/09)
FRONT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service

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

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
COMPLETE ALL SECTIONS, DATE, AND SIGN

I.

I,

, hereby voluntarily authorize the disclosure of information from my

health record.

(Name of Patient)

II. The information is to be disclosed by:

And is to be provided to:

NAME OF FACILITY

NAME OF PERSON/ORGANIZATION/FACILITY

ADDRESS

ADDRESS

CITY/STATE

CITY/STATE

III. The purpose or need for this disclosure is:
Further Medical Care

Attorney

School

Research

Personal Use

Insurance

Disability

Other (Specify)

IV. The information to be disclosed from my health record: (check appropriate box(es))
Only information related to (specify)

Only the period of events from
Other (specify) (CHS, Billing, etc.)
Entire Record

to

PROOF

If you would like any of the following sensitive information disclosed, check the applicable box(es) below:
Alcohol/Drug Abuse Treatment/Referral

HIV/AIDS-related Treatment

Sexually Transmitted Diseases

Mental Health (Other than Psychotherapy Notes)

Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient

V. I understand that I may revoke this authorization in writing submitted at any time to the Health Information Management Department, except to the
extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage
or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been
revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.

(Specify new date)

I understand that IHS will not condition treatment or eligibility for care on my providing this authorization except if such care is:
(1) research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.
I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to
redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part
164] , and the Privacy Act of 1974 [5 USC 552a].
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (State relationship to patient)

DATE

SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)

DATE

This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and willfully requests or
obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor (5 USC 552a(i)(3)).

PATIENT IDENTIFICATION

NAME (Last, FIrst, MI)

RECORD NUMBER

ADDRESS

CITY/STATE

DATE OF BIRTH

PSC Graphics (301) 443-1090

EF

IHS-810 (4/09)
BACK

Instructions for Completing IHS Form 810 -AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

1. Print legibly in all fields using dark permanent ink.
2. Section I, print your name or the name of patient whose information is to be released.
3. Section II, print the name and address of the facility releasing the information. Also, provide the name of
the person, facility and address that will receive the information.
4. Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care,
legal, research related projects, etc.
5. Section IV, check the appropriate box as applicable.
a. Only information related to -- specify diagnosis, injury, operations, special therapies, etc.
b. Only the period of events from -- specify date range, e.g., Jan. 1, 2002 to Feb. 1, 2002.
c. Other (specify) -- e.g., CHS, Billing, Employee Health.
d. Entire Record -- complete record including, if authorized, the sensitive information (alcohol and drug
abuse treatment/referral, sexually transmitted diseases, HIV/AIDS related treatment, and mental health
other than psychotherapy notes).

PROOF

e. IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOL/DRUG ABUSE
TREATMENT/ REFERRAL, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED
DISEASES, MENTAL HEALTH (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE
BOX MUST BE CHECKED BY THE PATIENT.
f.

Psychotherapy Notes ONLY -- IN ORDER TO AUTHORIZE THE USE OR DISCLOSURE OF
PSYCHOTHERAPY NOTES, ONLY THIS BOX SHOULD BE CHECKED ON THIS FORM.
AUTHORIZATIONS FOR THE USE OR DISCLOSURE OF OTHER HEALTH RECORD
INFORMATION MAY NOT BE MADE IN CONJUNCTION WITH AUTHORIZATIONS PERTAINING TO
PSYCHOTHERAPY NOTES.
IF THIS BOX IS CHECKED WITH OTHER BOXES, ANOTHER AUTHORIZATION WILL BE
REQUIRED TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES ONLY.
Psychotherapy notes are often referred to as process notes, distinguishable from progress notes in the
medical record. These notes capture the therapist’s impressions about the patient, contain details of the
psychotherapy conversation considered to be inappropriate for the medical record, and are used by the
provider for future sessions. These notes are often kept separate to limit access because they contain
sensitive information relevant to no one other than the treating provider.

6. Section V, if a different expiration date is desired, specify a new date.
7. Section V, Please sign (or mark) and date.
8. A copy of the completed IHS-810 form will be given to you.

OMB STATEMENT
Public reporting burden for this collection of information is estimated to average 20 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.