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 IHS-963 IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction	New
Form IHS-982 IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction	New
Form IHS- 917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction	Modified
Form IHS 913 IHS- 913, Request for Accounting of Disclosures Form and Instruction	Modified
Form IHS 912-2 IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction	Modified
Form IHS 912-1 IHS-912-1, Request for Restriction(s) Form and Instruction	Modified
OMB_No _0917-0030_Supporting_Statement_Final 9.20.23.docx Supporting Statement A	2023-09-21

IC Document Collections

IC ID	Document Title	Status
6589	IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction	Modified
262275	IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction	New
262274	IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction	New
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: 202309-0917-001
Status: Received in OIRA	Previous ICR Reference No: 201908-0917-001
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/21/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2023
Responses	211,517	211,264
Time Burden (Hours)	35,255	35,212
Cost Burden (Dollars)	0	0

---

Abstract: This is a request for a revision of a previously approved collection which is due to expire on September 30, 2023. 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:
	88 FR 42726	07/03/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 64915	09/20/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
IHS-912-1, Request for Restriction(s)	IHS 912-1	Request for Restriction(s)
IHS- 913, Request for Accounting of Disclosures	IHS 913	Request for Accounting of Disclosures
IHS- 917, Request for Correction/Amendment of Protected Health Information	IHS- 917	Request for Correction/Amendment of Protected Health Information
IHS-810, Authorization for Use or Disclosure of Protected Health Information	IHS 810	AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
IHS-912-2, Request for Revocation of Restriction(s)	IHS 912-2	Request for Revocation of Restriction(s
IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location	IHS-963	Request for Confidential Communication by Alternative Means or Alternate Location
IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information	IHS-982	Acknowledgement of receipt of the Notice of Privacy Practices Protected Health Information

---

ICR Summary of Burden

	Total Request	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	211,517	211,264	0	253	0	0
Annual Time Burden (Hours)	35,255	35,212	0	43	0	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: No

Burden Reduction Due to:

Short Statement: The Privacy program has included two new forms to accommodate programmatic changes, and to account for changes in patient services and communication methods over the last few years. The slight burden increase was to accommodate two new forms, which increased burden hours to accommodate both forms.

---

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

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

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: 09/21/2023

---