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.
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.
Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care,
legal, research-related projects, etc. For an Health Information Exchange (HIE) other than IHS, please
provide the name of the HIE.
5. Section IV, check the appropriate box as applicable.
Only information related to -- specify diagnosis, injury, operations, special therapies, etc.
Only the period of events from -- specify date range, e.g., Jan. 1, 2002, to Feb. 1, 2002.
Other (specify) -- e.g., Purchased Referred Care (PRC), Billing, Employee Health.
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).
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.
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
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.
When you opt-in to share information through the HIE, an expiration date must be entered.
Section V, if a different expiration date is desired, specify a new date. For HIE, a date 5 years in the future
is recommended in order to provide health information for continuity of care.
Section V, Please sign (or mark) and date.
A copy of the completed IHS-810 form will be given to you.8.
Public reporting burden for this collection of information is estimated to average 10 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, Office of Management Services, Division of Regulatory Affairs, Mail
Stop 09E70, 5600 Fishers Lane, Rockville, MD 20857, RE: OMB No. 0917-0030. Please DO NOT SEND this form to this address.