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PATIENT IDENTIFICATION NAME Last First MI RECORD NUMBER DATE OF BIRTH PSC Graphics 301 443-1090 EF BACK Instructions for Completing IHS Form 810 -AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. IHS-810 4/09 FRONT FORM APPROVED OMB NO. 0917-0030 Expiration Date 1/31/2013 See OMB Statement on Reverse. DEPARTMENT OF HEALTH AND HUMAN SERVICES Indian Health Service AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION COMPLETE ALL SECTIONS DATE AND SIGN I. DEPARTMENT OF HEALTH AND HUMAN SERVICES Indian Health Service AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION COMPLETE ALL SECTIONS DATE AND SIGN I. I hereby voluntarily authorize the disclosure of information from my health record. Name of Patient II. If this authorization has not been revoked it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date 1 research related or 2 provided solely for the pur....

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Related content

FORM IHS-810 - HHS.gov
0917-0030. Expiration Date: 07-31-2020. See OMB Statement on Reverse. DEPARTMENT OF HEALTH...
Learn more
IHS810 Authorization for Use or Disclosure of...
DEPARTMENT OF HEALTH AND HUMAN SERVICES. Indian Health ... 0917-0030. Expiration Date:...
Learn more

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232