Public Use Forms
The following is a list of IHS Public Use Forms. These forms have been approved by OMB. Questions or Comments, please contact the Content Manager.Right click on the appropriate file and select "Save Target As" if you wish to save the file to your hard drive.
Document:
IHS-843-1A : Order for Health Services [PDF - 264KB]
OMB Number: 0917-0002
Exp. Date: 2/28/2013
Created Date: 6/09
Document:
IHS-810 : Authorization For Use or Disclosure of Protected Health Information [PDF - 416KB]
OMB Number: 0917-0030
Exp. Date: 1/31/2013
Created Date: 4/09
Note: This form is currently being reviewed by OMB to renew the expiration date. Continue using the current form (expiration 01-31-2013) until IHS receives approval from OMB.
Document:
IHS-963 : Request for Confidential Communication by Alternate Means or Alternate Location [PDF - 290KB]
OMB Number: NA
Exp. Date: NA
Created Date: 4/09
Document:
IHS-912-1 : Request For Restriction(s) [PDF - 311KB]
OMB Number: 0917-0030
Exp. Date: 1/31/2013
Created Date: 4/09
Note: This form is currently being reviewed by OMB to renew the expiration date. Continue using the current form (expiration 01-31-2013) until IHS receives approval from OMB.
Document:
IHS-912-2 : Request For Revocation of Restriction(s) [PDF - 344KB]
OMB Number: 0917-0030
Exp. Date: 1/31/2013
Created Date: 4/09
Note: This form is currently being reviewed by OMB to renew the expiration date. Continue using the current form (expiration 01-31-2013) until IHS receives approval from OMB.
Document:
IHS-913 : Request For An Accounting of Disclosures [PDF - 330KB]
OMB Number: 0917-0030
Exp. Date: 1/31/2013
Created Date: 4/09
Note: This form is currently being reviewed by OMB to renew the expiration date. Continue using the current form (expiration 01-31-2013) until IHS receives approval from OMB.
Document:
IHS-917 : Request for Correction/Amendment of Protected Health Information [PDF - 290KB]
OMB Number: 0917-0030
Exp. Date: 1/31/2013
Created Date: 4/09
Note: This form is currently being reviewed by OMB to renew the expiration date. Continue using the current form (expiration 01-31-2013) until IHS receives approval from OMB.
