Form 917 Request for correction/Amendment of Protected Health Inf

IHS-917 FRONT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED: OMB NO. 0917-0030

Expiration Date: X/XX/2019

See OMB Statement on Reverse.

Indian Health Service

REQUEST FOR CORRECTION/AMENDMENT OF PROTECTED HEALTH INFORMATION

PATIENT NAME

DATE OF BIRTH

PATIENT RECORD NUMBER

PATIENT ADDRESS

Please explain how the entry is incorrect or incomplete. What should the entry say to be more accurate or complete? Use additional sheets if needed and attach to this form.

If you agree, IHS will make a reasonable effort to provide the amendment to other persons who IHS knows received the information in the past and who may have relied, or are likely to rely, on such information in a manner that may be detrimental to your health care.

I agree to allow IHS to release any amended information to individuals or entities as described above.

Would you like this amendment sent to anyone else who received the information in the past? If yes, please specify the name and address of the organization(s) or individual(s).

Yes No

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (If Personal Representative, state relationship to patient)	DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)	DATE

FOR IHS USE ONLY

IF DENIED, CHECK REASON FOR DENIAL

Protected Health Information (PHI) is not part of the patient’s designated record set

IHS did not create record

Record is not available to the patient for inspection under Federal law

Record is accurate and complete

COMMENTS OF HEALTHCARE PROVIDER (If applicable)

SIGNATURE OF HEALTHCARE PROVIDER (If applicable)	TITLE	DATE
SIGNATURE OF CHIEF EXECUTIVE OFFICER (CEO) OR DESIGNEE		DATE

PSC Graphics (301) 443-1090 EF

IHS-917 BACK

Instructions for Completing IHS Form 917 --

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Request for Correction/Amendment of Protected Health Information (PHI)

Print legibly in all fields using dark permanent ink. Sign and date the request.

Submit the completed and signed form to the Chief Executive Officer (CEO) or designee.

You will receive a photocopy of your completed form, as an acknowledgement of receipt of your request, no later than 10 business days after IHS receives your request.

You will be notified of the acceptance or denial of your request.

If you agree to allow IHS to release any amended information and if your request to amend is accepted:

1. If you are a U.S. citizen or alien lawfully admitted for permanent residence, IHS is required by law to notify any previous recipient of the record in question of the corrective action taken, if IHS made an accounting of such disclosure.

2. Regardless of your citizenship status, IHS will make reasonable efforts to send any amended or corrected information to anyone who IHS knows received this information in the past and who may have relied, or is likely to rely, on such information to your detriment.

3. IHS will make reasonable efforts to send the correction or amendment to those individuals or entities/ organizations you identify and who have a need for the correction or amendment.

If you are not a U.S. citizen or alien lawfully admitted for permanent residence, and your request is denied, you may do the following:

1. Submit to the Service Unit CEO a one page written statement disagreeing with the denial and the basis of such disagreement.

2. If you do not submit a statement of disagreement, you may request that IHS provide this request for correction or amendment (or summary) and the denial with any future disclosures.

3. IHS has the right to prepare a written rebuttal to any statement of disagreement. You will be provided a copy of any rebuttal statement. Any written rebuttal prepared by IHS is not subject to correction or amendment.

If you are a U.S. citizen or alien lawfully admitted for permanent residence, and your request is denied, you may do the following:

1. Appeal the refusal to correct or amend the requested information to the Area Director.

2. In the event your appeal is ultimately denied, or if you elect not to appeal, you may submit a statement of disagreement or request as described in 7(a) and 7(b) above.

3. IHS has the right to prepare a written rebuttal to any statement of disagreement. You will be provided a copy of any rebuttal statement. Any written rebuttal prepared by IHS is not subject to correction or amendment.

4. In addition, if your appeal is denied, you may seek judicial review of the decision.

If you have a complaint about IHS’ policies and procedures regarding health information, you may file such a complaint with the Service Unit CEO; Department of Health and Human Services, Office for Civil Rights; or with the Secretary, Department of Health and Human Services, Washington, DC 20201.

This form and subsequent information pertaining to this request will become part of your permanent health record.

FOR IHS CEO: Insert Service Unit address, CEO’s name & Title, and Telephone # into area below.

OMB BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 10 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville, MD 20857, RE: OMB Control No. 0917-0030. Please DO NOT SEND this form to this address.