Information Collection

IHS-810, Authorization for Use or Disclosure of Protected Health Information

IC 6589 under ICR 201301-0917-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0030, IHS-810 IHS-810, Authorization for Use or Disclosure of Protected Health Information	Form and Instruction
0917-0030, IHS-810 Authorization for Use or Disclosure of Protected Health IHS-810_508.pdf www.ihs.gov/CIO/PUF/	Form and Instruction

IC Title:

IHS-810, Authorization for Use or Disclosure of Protected Health Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0030, IHS-810	Authorization for Use or Disclosure of Protected Health Information	IHS-810_508.pdf	http://www.ihs.gov/CIO/PUF/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records

FR Citation: 75 FR 1625

Number of Respondents: 500,000

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	Previously Approved
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	166,667	166,667
Annual IC Cost Burden (Dollars)	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.