OMB control number

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

OMB 0917-0030 · HHS/IHS.

OMB 0917-0030

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.

The latest form for IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164) expires 2026-12-31 and is listed under ICR 202309-0917-001.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form IHS 810 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION	Form and Instruction
Form IHS 810 IHS-810, Authorization for Use or Disclosure of Protected Health Information	Form and Instruction
Form IHS-963 Request for Confidential Communication by Alternative Means or Alternate Location	Form and Instruction
Form IHS-963 IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location	Form and Instruction
Form IHS-982 Acknowledgement of receipt of the Notice of Privacy Practices Protected Health Information	Form and Instruction
Form IHS-982 IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information	Form and Instruction
Form IHS- 917 Request for Correction/Amendment of Protected Health Information	Form and Instruction
Form IHS- 917 IHS- 917, Request for Correction/Amendment of Protected Health Information	Form and Instruction
Form IHS 913 Request for Accounting of Disclosures	Form and Instruction
Form IHS 913 IHS- 913, Request for Accounting of Disclosures	Form and Instruction
Form IHS 912-2 Request for Revocation of Restriction(s	Form and Instruction
Form IHS 912-2 IHS-912-2, Request for Revocation of Restriction(s)	Form and Instruction
Form IHS 912-1 Request for Restriction(s)	Form and Instruction
Form IHS 912-1 IHS-912-1, Request for Restriction(s)	Form and Instruction
OMB_No _0917-0030_Supporting_Statement_Final 9.20.23.docx	Supporting Statement A
IHS-810, Authorization for Use or Disclosure of Protected Health Information	Form and Instruction
IHS-810, Authorization for Use or Disclosure of Protected Health Information	Form and Instruction
IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location	Form and Instruction
IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location	Form and Instruction
IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information	Form and Instruction
IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information	Form and Instruction
IHS- 917, Request for Correction/Amendment of Protected Health Information	Form and Instruction
IHS- 917, Request for Correction/Amendment of Protected Health Information	Form and Instruction
IHS- 913, Request for Accounting of Disclosures	Form and Instruction
IHS- 913, Request for Accounting of Disclosures	Form and Instruction
IHS-912-2, Request for Revocation of Restriction(s)	Form and Instruction
IHS-912-2, Request for Revocation of Restriction(s)	Form and Instruction
IHS-912-1, Request for Restriction(s)	Form and Instruction
IHS-912-1, Request for Restriction(s)	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202309-0917-001	Revision of a currently approved collection	2023-09-21	Approved without change
201908-0917-001	Extension without change of a currently approved collection	2019-08-21	Approved without change
201603-0917-001	Extension without change of a currently approved collection	2016-03-28	Approved with change
201301-0917-002	Extension without change of a currently approved collection	2013-01-22	Approved without change
200911-0917-001	Revision of a currently approved collection	2009-11-25	Approved without change
200608-0917-002	Extension without change of a currently approved collection	2006-08-28	Approved without change
200304-0917-001	Extension without change of a currently approved collection	2003-04-10	Approved without change
200303-0917-001	New collection (Request for a new OMB Control Number)	2003-03-21	Approved without change

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form IHS 810	AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.