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

Form IHS-810 PDF Details

If this authorization has not been revoked, it will terminate one year from the date of the signature unless a different expiration date or expiration event is stated.

Revoke: in writing submitted at any time to the Health Information Management Department.

Reliance: except to the extent that action has been taken in reliance on this authorization.

Treatment: IHS will not condition treatment or eligibility for care on providing this authorization.

Psychotherapy notes: in order to authorize their use or disclosure, only this box should be checked on this form.

Witness: signature of witness if signature of patient is a thumbprint or mark.

Copy: a copy of the completed IHS-810 form will be given to you.