OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201301-0917-002 · OMB 0917-0030 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0917-0030, IHS-810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction Modified Repair queued
Form 0917-0030, IHS-917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction Modified Repair queued
Form 0917-0030 IHS- 913, Request for Accounting of Disclosures Form and Instruction Modified Repair queued
Form 0917-0030-IHS-912- IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction Modified Repair queued
Form 0917-0030, IHS-912 IHS-912-1, Request for Restriction(s) Form and Instruction Modified Repair queued
IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records.pdf Supplementary Document Uploaded 2013-01-18 Repair queued
OMB_No._0917-0030_Supporting_Statement_FINAL_1-10-13[2].doc Supporting Statement A Uploaded 2013-01-14 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
6589 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction Modified
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
0917-0030 201301-0917-002
Historical Active 200911-0917-001
HHS/IHS 17299
IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Extension without change of a currently approved collection   No
Regular
Approved without change 04/01/2013
Retrieve Notice of Action (NOA) 01/22/2013
  Inventory as of this Action Requested Previously Approved
04/30/2016 36 Months From Approved 03/31/2013
542,500 0 542,500
174,375 0 174,375
0 0 0
This is a request for an extension without a revision of a previously approved collection which is due to expire January 31, 2013. 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.
PL: Pub.L. 104 - 191 264 Name of Law: Health Insurance Portability and Accountability Act
  
None
Not associated with rulemaking
  77 FR 60129 10/02/2012
78 FR 2412 01/11/2013
No
  Total Approved 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 542,500 542,500 0 0 0 0
Annual Time Burden (Hours) 174,375 174,375 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$1,260,000
No
No
No
No
No
Uncollected
Tamara Clay 301 443-4750 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/22/2013