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 202309-0917-001 · OMB 0917-0030 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form IHS 810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction Modified Repair queued
Form IHS-963 IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction New Repair queued
Form IHS-982 IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction New Repair queued
Form IHS- 917 IHS- 917, Request for Correction/Amendment of Protected Health Information Form and Instruction Modified Repair queued
Form IHS 913 IHS- 913, Request for Accounting of Disclosures Form and Instruction Modified Repair queued
Form IHS 912-2 IHS-912-2, Request for Revocation of Restriction(s) Form and Instruction Modified Repair queued
Form IHS 912-1 IHS-912-1, Request for Restriction(s) Form and Instruction Modified Repair queued
OMB_No _0917-0030_Supporting_Statement_Final 9.20.23.docx Supporting Statement A Uploaded 2023-09-21 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
6589 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction Modified
262275 IHS-963, Request for Confidential Communication by Alternative Means or Alternate Location Form and Instruction New
262274 IHS-982, Acknowledgement of Receipt of the Notice of Privacy Practices Protected Health Information Form and Instruction New
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 202309-0917-001
Received in OIRA 201908-0917-001
HHS/IHS 0917-0030
IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Revision of a currently approved collection   No
Regular 09/21/2023
  Requested Previously Approved
36 Months From Approved 09/30/2023
211,517 211,264
35,255 35,212
0 0
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.
PL: Pub.L. 104 - 191 264 Name of Law: Health Insurance Portability and Accountability Act
  
None
Not associated with rulemaking
  88 FR 42726 07/03/2023
88 FR 64915 09/20/2023
No
  Total Request 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 211,517 211,264 0 253 0 0
Annual Time Burden (Hours) 35,255 35,212 0 43 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The Privacy program has included two new forms to accommodate programmatic changes, and to account for changes in patient services and communication methods over the last few years. The slight burden increase was to accommodate two new forms, which increased burden hours to accommodate both forms.
$1,020,000
No
    Yes
    Yes
No
No
No
No
Evonne Bennett-Barnes 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.
09/21/2023