IHS Form 810

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⚠️ Notice: This information collection may be referencing outdated material.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-810 IHS Form 810 Form and Instruction
IHS-810 Authorization for Use or Disclosure of Protected Health IHS-810(9-25-09).pdf Form and Instruction
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf 60 Day Federal Register Notice IC Document
30DAYIHSFORMS 11-20-09.pdf 30 Day Federal Register Notice IC Document

Information Collection (IC) Details

IC Title:	IHS Form 810	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	IHS-810	Authorization for Use or Disclosure of Protected Health Information	IHS-810(9-25-09).pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500,000	-42,500	542,500
Annual IC Time Burden (Hours)	166,667	161,242	5,425
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
60 Day Federal Register Notice	PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	11/12/2009
30 Day Federal Register Notice	30DAYIHSFORMS 11-20-09.pdf	11/25/2009

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