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

Forms and Documents

Document Name	Status
Form IHS 810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction	Modified
Form 917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction	Modified
Form 913 IHS- 913, Request for Accounting of Disclosures Form and Instruction	Modified
Form 912-2 IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction	Modified
Form 912-1 IHS-912-1, Request for Restriction(s) Form and Instruction	Modified
FINAL OMB_No _0917-0030_Supporting_Statement_Final TClay 3-22-2016_OMBcomments.docx Supporting Statement A	2016-08-24
IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records.pdf Supplementary Document	2013-01-18

IC Document Collections

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

ICR Details

OMB Control No: 0917-0030	ICR Reference No: 201603-0917-001
Status: Historical Active	Previous ICR Reference No: 201301-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No: 0917-0030
Title: IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/30/2016
	Date Received in OIRA: 03/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	211,264	0	542,500
Time Burden (Hours)	35,212	0	174,375
Cost Burden (Dollars)	0	0	0

---

Abstract: This is a request for an extension without a revision of a previously approved collection which is due to expire April 30, 2016. 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.

---

Authorizing Statute(s): PL: Pub.L. 104 - 191 264 Name of Law: Health Insurance Portability and Accountability Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 3806	01/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 15347	03/22/2016
Did the Agency receive public comments on this ICR? No

---

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

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

---

ICR Summary 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	211,264	542,500	0	0	-331,236	0
Annual Time Burden (Hours)	35,212	174,375	0	0	-139,163	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There are no program changes or adjustments. There was a change in IHS-810 Form to include an option for the respondents to release information to Health Information Exchanges. This change is due to the technology solution to share patient information electronically in order to meet Meaningful Use Stage 2 with the IHS’s certified electronic health record, as required by 42 C.F.R. Parts 412, 413, and 495. The program also made a discretionary change in the burden hours; decreasing the burden hours on two forms, the IHS-810 and IHS-917, from 20 minutes to 10 minutes to more accurately reflect the actual time it takes to complete the form(s). Additionally, the number of respondents were decreased for all five forms to reflect actual baseline numbers collected and provided by the Area Health Information Managers (HIMs). Also, in the table under 12B., “estimated annual costs to respondents for this collection,” the hourly wage rate for respondents was changed from $19 per hour to $17 per hour to more accurately reflect the actual wages of American Indians and Alaska Natives (AIAN). The average annual income of American Indians was $36,252 and the poverty rate was 29%, in 2014 (United States Census Bureau, 2015) (See US Census webpage, “Facts for Features: American Indian and Alaska Native Heritage Month: November 2014” at http://www.census.gov/newsroom/facts-for-features/2014/cb14-ff26.html). Further, the average annual income for AIANs may even be lower as the United States Bureau of Labor Statistics (BLS) reported a 54% population-employment ratio for AIANs, with an 11.3% average unemployment rate. (See BLS report “Labor Force Statistics by Race and Ethnicity, 2014” at http://www.bls.gov/opub/reports/cps/labor-force-characteristics-by-race-and-ethnicity-2014.pdf).

---

Annual Cost to Federal Government: $1,020,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 03/25/2016

---