IHS 913 Request for Accounting of Disclosures

IHS-913

FORM APPROVED: OMB NO. 0917-0030

Expiration Date: X/XX/2019

See OMB Statement below.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service

REQUEST FOR AN ACCOUNTING OF DISCLOSURES

DATE OF REQUEST	PATIENT NAME
HEALTH RECORD NUMBER		DATE OF BIRTH

PATIENT ADDRESS

The information is to be disclosed by:

NAME OF FACILITY

ADDRESS

I would like an accounting of disclosures for the following time frame (e.g., From: 01/01/16 To: 01/30/16)

From:

To:

If you are only seeking an accounting of a certain type(s) of disclosure or disclosures to a specific person/ organization, please describe the disclosures for which you are seeking an accounting:

I understand that the accounting will be provided to me within 60 days of the date of this request, unless IHS extends the time frame for an additional 30 days and provides me with a written statement for the reason(s) for the delay and the date by which I can expect to receive the accounting.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (If Personal Representative, state relationship to patient)	DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)	DATE

FOR IHS USE ONLY

NAME/TITLE OF IHS EMPLOYEE PROCESSING REQUEST

OMB BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0030. The time required to complete this information collection is estimated to average less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857, Attention: Information Collections Clearance Officer.

PSC Graphics (301) 443-1090 EF