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

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

OMB: 0917-0030

IC ID: 6589

Information Collection (IC) Details

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IHS-810, Authorization for Use or Disclosure of Protected Health Information
 
No Modified
 
Voluntary
 

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_08-17-16.pdf Yes No Fillable Printable

Health Health Care Services

IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records  75 FR 1625

210,954 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 210,954 0 0 -289,046 0 500,000
Annual IC Time Burden (Hours) 35,159 0 0 -131,508 0 166,667
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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