IHS-912-1, Request for Restriction(s)

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

Documents and Forms

Document Name Document Type
Form IHS 912-1 IHS-912-1, Request for Restriction(s) Form and Instruction
IHS 912-1 Request for Restriction(s) IHS-912-1_508 - 2023.docx Form and Instruction
IHS 912-1 Request for Restriction(s) IHS-912-1_508 - 2023.docx Form and Instruction

Information Collection (IC) Details

IC Title:	IHS-912-1, Request for Restriction(s)	Agency IC Tracking Number:	IHS 912-1

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	IHS 912-1	Request for Restriction(s)	IHS-912-1_508 - 2023.docx		Yes	No	Fillable Fileable

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: 214	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	214	214
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.