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Get HHS IHS-810 2016-2021

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 If this authorization has not been revoked it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.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.

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