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

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

Documents and Forms

Document Name Document Type
Form IHS 810 IHS-810, Authorization for Use or Disclosure of Protected Health Information Form and Instruction
IHS 810 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH IHS-810 Final 9-8-2023.docx Form and Instruction
IHS 810 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH IHS-810 Final 9-8-2023.docx Form and Instruction

Information Collection (IC) Details

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	IHS 810	AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION	IHS-810 Final 9-8-2023.docx		Yes	No	Fillable Fileable

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: 210,954	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	210,954	210,954
Annual IC Time Burden (Hours)	35,159	35,159
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.