Form Ihs 810 PDF Details

In the landscape of healthcare documentation and privacy, the IHS 810 form emerges as a crucial instrument within the Department of Health and Human Services, specifically tailored for the Indian Health Service constituents. Approved under the OMB NO. 0917-0030 with an expiration date of 4/30/2016, this form serves a vital role in authorizing the use or disclosure of protected health information. It mandates the completion of all sections, alongside the requisite date and signatures, to facilitate the sharing of health records between entities for varying purposes such as further medical care, personal use, legal proceedings, insurance matters, educational needs, disability claims, research, and more. The form intricately details the specificity of the information to be disclosed, whether it pertains to certain health conditions, a specified period of events, or the entirety of one's health record, including sensitive information like treatment for alcohol/drug abuse, sexually transmitted diseases, HIV/AIDS-related treatment, mental health issues, and psychotherapy notes. In recognizing the potential implications of such disclosures, the form outlines conditions under which the authorization may be revoked, the stipulated expiration of the consent unless otherwise stated, and the understanding that the information shared may be subject to redisclosure and thus might not remain protected under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule or the Privacy Act of 1974. This comprehensive approach underscores the form's significance in balancing the need for information sharing with the imperative of safeguarding patient privacy.

QuestionAnswer
Form NameForm Ihs 810
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesihs 810 form, omb no 0917 0030, 810 form, form ihs 810

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED: OMB NO. 0917-0030

Expiration Date: 4/30/2016

 

Indian Health Service

SEE OMB STATEMENT ON REVERSE.

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

COMPLETE ALL SECTIONS, DATE, AND SIGN

I.I,

health record.

, hereby voluntarily authorize the disclosure of information from my

(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

ADDRESS

CITY/STATE

CITY/STATE

III.The purpose or need for this disclosure is:

Further Medical Care

Personal Use

Attorney

Insurance

School

Disability

Research

Other (Specify)

IV. The information to be disclosed from my health record: (check appropriate box(es))

Only information related to (specify)

Only the period of events from

 

to

 

Other (specify) (CHS, Billing, etc.)

 

 

 

Entire Record

 

 

If you would like any of the following sensitive information disclosed, check the applicable box(es) below:

Alcohol/Drug Abuse Treatment/Referral

Sexually Transmitted Diseases

HIV/AIDS-related Treatment

Mental Health (Other than Psychotherapy Notes)

Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient privilege)

V.I understand that I may revoke this authorization in writing submitted at any time to the Health Information Management Department, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. 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)

I understand that IHS will not condition treatment or eligibility for care on my providing this authorization except if such care is:

(1) research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.

I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164] , and the Privacy Act of 1974 [5 USC 552a].

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (State relationship to patient)

DATE

SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)

DATE

This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and willfully requests or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor (5 USC 552a(i)(3)).

PATIENT IDENTIFICATION

NAME (Last, First, MI)

RECORD NUMBER

ADDRESS

CITY/STATE

DATE OF BIRTH

IHS-810 (4/09) FRONT

PSC Publishing Services (301) 443-6740 EF

Instructions for Completing IHS Form 810 --

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

1.Print legibly in all fields using dark permanent ink.

2.Section I, print your name or the name of patient whose information is to be released.

3.Section II, print the name and address of the facility releasing the information. Also, provide the name of the person, facility, and address that will receive the information.

4.Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care, legal, research-related projects, etc.

5.Section IV, check the appropriate box as applicable.

a.Only information related to -- specify diagnosis, injury, operations, special therapies, etc.

b.Only the period of events from -- specify date range, e.g., Jan. 1, 2002, to Feb. 1, 2002.

c.Other (specify) -- e.g., CHS, Billing, Employee Health.

d.Entire Record -- complete record including, if authorized, the sensitive information (alcohol and drug abuse treatment/referral, sexually transmitted diseases, HIV/AIDS-related treatment, and mental health other than psychotherapy notes).

e.IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOL/DRUG ABUSE TREATMENT/REFERRAL, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED BY THE PATIENT.

f.Psychotherapy Notes ONLY -- IN ORDER TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES, ONLY THIS BOX SHOULD BE CHECKED ON THIS FORM. AUTHORIZATIONS FOR THE USE OR DISCLOSURE OF OTHER HEALTH RECORD INFORMATION MAY NOT BE MADE IN CONJUNCTION WITH AUTHORIZATIONS PERTAINING TO PSYCHOTHERAPY NOTES.

IF THIS BOX IS CHECKED WITH OTHER BOXES, ANOTHER AUTHORIZATION WILL BE REQUIRED TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES ONLY.

Psychotherapy notes are often referred to as process notes, distinguishable from progress notes in the medical record. These notes capture the therapist’s impressions about the patient, contain details of the psychotherapy conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. These notes are often kept separate to limit access because they contain sensitive information relevant to no one other than the treating provider.

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. 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., TMP Suite 450, Rockville, MD 20852, RE: PRA 0917-0030. Please DO NOT SEND this form to this address.

IHS-810 (4/09) BACK

How to Edit Form Ihs 810 Online for Free

Whenever you would like to fill out ihs release of information form, there's no need to download any sort of applications - simply try using our online PDF editor. Our editor is continually developing to give the very best user experience achievable, and that is thanks to our resolve for continuous improvement and listening closely to feedback from users. This is what you would have to do to get going:

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Step 2: As you start the editor, you'll notice the document prepared to be filled in. In addition to filling in various fields, you could also do some other actions with the file, particularly writing your own words, changing the initial text, adding illustrations or photos, putting your signature on the document, and more.

It really is easy to complete the form with this detailed guide! Here's what you need to do:

1. When completing the ihs release of information form, make certain to incorporate all essential blanks within its corresponding section. This will help to facilitate the work, allowing for your information to be processed fast and correctly.

omb no 0917 0030 writing process explained (step 1)

2. The subsequent stage is usually to fill out these particular blanks: Sexually Transmitted Diseases, Mental Health Other than, Psychotherapy Notes ONLY by, I understand that I may revoke, I understand that IHS will not, I understand that information, Specify new date, SIGNATURE OF PATIENT OR PERSONAL, SIGNATURE OF WITNESS If signature, DATE, DATE, This information is to be released, NAME Last First MI, and RECORD NUMBER.

Ways to fill in omb no 0917 0030 stage 2

3. Completing PATIENT IDENTIFICATION, NAME Last First MI, RECORD NUMBER, ADDRESS, CITYSTATE, DATE OF BIRTH, IHS FRONT, and PSC Publishing Services EF is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Filling out part 3 in omb no 0917 0030

It is possible to get it wrong when completing your DATE OF BIRTH, for that reason be sure you reread it before you send it in.

Step 3: Prior to moving on, ensure that blanks were filled in correctly. When you believe it is all good, click on “Done." Join FormsPal today and easily get access to ihs release of information form, all set for download. All changes made by you are preserved , making it possible to modify the pdf later on if required. At FormsPal.com, we strive to be sure that your information is kept secure.