Form Ihs 963 PDF Details

Within the realm of patient privacy and the customization of healthcare communication, the IHS-963 form plays a pivotal role, particularly for individuals who rely on the services of the Indian Health Service (IHS), a sector of the Department of Health and Human Services. This form is a gateway for patients seeking to receive their health information through non-standard means or at alternative locations, tailored to their unique circumstances or needs. Intended to safeguard patient privacy while ensuring the seamless transfer of critical health information, the IHS-963 form allows for requests including but not limited to communication via regular mail, telephone, or facsimile. However, it's important for patients to be aware that choosing certain alternative communication methods, like fax, may introduce risks, such as potential interception by unauthorized parties, for which the IHS does not take responsibility. Furthermore, email communication, despite its ubiquity, is currently not supported as an alternative communication method by the IHS. In addition to specifying the mode of communication or alternate address, patients must also delineate the scope of information to be communicated and the duration for which the request is valid. It's also critical for the request to be accompanied by the necessary consents and, if applicable, information concerning the handling of service fees. The process outlined in the form underscores the IHS’s commitment to patient autonomy, privacy, and the adaptability of healthcare services to meet individual needs while also highlighting certain limitations and responsibilities incumbent on the patient.

Form NameForm Ihs 963
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesGraphics, PSC, applicable, form 963

Form Preview Example

IHS-963 (4/09)





Indian Health Service














, Date of Birth

request an alternative means of

communication of my health information (e.g., regular mail, telephone, facsimile) or communication of my health information to an alternate location.

I understand that request for communication by alternative means or to an alternate location is applicable only to information held by the Indian Health Service (IHS) and disclosure by alternative means may not be protected and could endanger me. I understand that request for FAX communication may be intercepted by others and IHS is not responsible if such intercepts occur.

(NOTE: IHS is unable to accept e-mail addresses as an alternative means of communication at this time.)

Please describe in detail your proposed alternative means or alternate location for receiving communications from IHS:

Alternate Mailing Address:

Alternate Phone Number:

Alternate Means of Contact (Please Specify):

This request applies to the following information:

Today’s Date of Service only




Until Further Notice

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (If Personal Representative, state relationship to patient)


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



Request Approved


If denied, reason (check one):

Request is not reasonable to accommodate

Alternate address or contact not provided

Failure to provide information on how payment will be made (if applicable)

Other (please explain):

PSC Graphics (301) 443-1090 EF

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Step no. 1 of completing IHS

2. Once your current task is complete, take the next step – fill out all of these fields - Alternate Phone Number, Alternate Means of Contact Please, This request applies to the, Todays Date of Service only, From, From, Until Further Notice, SIGNATURE OF PATIENT OR PERSONAL, SIGNATURE OF WITNESS If signature, DATE, DATE, Request Approved, Denied, If denied reason check one, and FOR IHS USE ONLY with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Simple tips to fill out IHS stage 2

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Request is not reasonable to, Alternate address or contact not, and Failure to provide information on in IHS

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