Loading
Form preview picture

Get HHS IHS-810 2016-2024

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 If this authorization has not been revoked it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.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 purpose of creating Protected Health Information for disclosure to a third party. 6. Section V if a different expiration date is desired specify a new date. 7. Section V Please sign or mark and date. 8. A copy of the completed IHS-810 form will be given to you. OMB STATEMENT Public reporting burden for this collection of information is estimated to average 20 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. 8. A copy of the completed IHS-810 form will be given to you. OMB STATEMENT Public reporting burden for this collection of information is estimated to average 20 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 Indian Health Service 801 Thompson Ave. I hereby voluntarily authorize the disclosure of information from my health record. Name of Patient II. The information is to be disclosed by And is to be provided to NAME OF FACILITY NAME OF PERSON/ORGANIZATION/FACILITY ADDRESS CITY/STATE III. The purpose or need for this disclosure is Further Medical Care Attorney School Research Personal Use Insurance Disability Other Specify Only information related to specify Only the period of events from to Entire Record If you would like any of the following sensitive information disclosed check the applicable box es below Alcohol/Drug Abuse Treatment/Referral HIV/AIDS-related Treatment Sexually Transmitted Diseases Mental Health Other than Psychotherapy Notes Psychotherapy Notes ONLY by checking this box I am waiving any psychotherapist-patient privilege V.

How It Works

form ihs 810 rating
4.8Satisfied
49 votes

Tips on how to fill out, edit and sign 810 ihs forms online

How to fill out and sign Form protected health online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Business, legal, tax along with other e-documents need a high level of protection and compliance with the legislation. Our documents are updated on a regular basis in accordance with the latest amendments in legislation. Plus, with our service, all of the details you provide in your HHS IHS-810 is well-protected from leakage or damage through top-notch file encryption.

The tips below will allow you to fill in HHS IHS-810 easily and quickly:

  1. Open the form in the full-fledged online editing tool by hitting Get form.
  2. Fill in the required boxes which are colored in yellow.
  3. Press the green arrow with the inscription Next to move on from one field to another.
  4. Go to the e-signature tool to add an electronic signature to the template.
  5. Add the date.
  6. Double-check the entire template to make sure you haven?t skipped anything important.
  7. Hit Done and download the resulting template.

Our solution enables you to take the whole procedure of completing legal forms online. As a result, you save hours (if not days or weeks) and eliminate extra costs. From now on, complete HHS IHS-810 from the comfort of your home, workplace, as well as on the go.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing form ihs

Go paperless, fill and adjust your Form online using expert-generated templates. This video guide will provide you with all the information and know-how you need to start now.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to HHS IHS-810

  • cfr
  • USC
  • insurer
  • Rockville
  • PSC
  • chs
  • legibly
  • portability
  • 09e70
  • redisclosure
  • jan
  • FEB
  • prc
  • false
  • Authorizations
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.