Information Collection

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

IC 6589 under ICR 201301-0917-002 · OMB 0917-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0030 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0030, IHS-810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction
0917-0030, IHS-810 Authorization for Use or Disclosure of Protected Health IHS-810_508.pdf www.ihs.gov/CIO/PUF/ Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	IHS-810, Authorization for Use or Disclosure of Protected Health Information	Agency IC Tracking Number:

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	0917-0030, IHS-810	Authorization for Use or Disclosure of Protected Health Information	IHS-810_508.pdf	http://www.ihs.gov/CIO/PUF/	Yes	No	Fillable Printable

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: 500,000	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	500,000	500,000
Annual IC Time Burden (Hours)	166,667	166,667
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.