Fillable FORM APPROVED: OMB NO. 0917-0030: REQUEST FOR CORRECTION/AMENDMENT (Indian Health Service / Office of IT)

Fill Online, Printable, Fillable, Blank FORM APPROVED: OMB NO. 0917-0030: REQUEST FOR CORRECTION/AMENDMENT (Indian Health Service / Office of IT) Form

Use Fill to complete blank online INDIAN HEALTH SERVICE (USA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FORM APPROVED: OMB NO. 0917-0030: REQUEST FOR CORRECTION/AMENDMENT (Indian Health Service / Office of IT)

On average this form takes 5 minutes to complete

The FORM APPROVED: OMB NO. 0917-0030: REQUEST FOR CORRECTION/AMENDMENT (Indian Health Service / Office of IT) form is 2 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Indian Health Service

BROWSE INDIAN HEALTH SERVICE (USA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR CORRECTION/AMENDMENT OF PROTECTED HEALTH INFORMATION
FORM APPROVED: OMB NO. 0917-0030
Expiration Date: 07-31-2020
See OMB Statement on Reverse.
PATIENT NAME DATE OF BIRTH PATIENT RECORD NUMBER
PATIENT ADDRESS
DATE OF ENTRY TO BE CORRECTED/AMENDED INFORMATION TO BE CORRECTED/AMENDED
Please explain how the entry is incorrect or incomplete. What should the entry say to be more accurate or complete?
Use additional sheets if needed and attach to this form.
If you agree, IHS will make a reasonable effort to provide the amendment to other persons who IHS knows received
the information in the past and who may have relied, or are likely to rely, on such information in a manner that may
be detrimental to your health care.
I agree to allow IHS to release any amended information to individuals or entities as described above.
Would you like this amendment sent to anyone else who received the information in the past?
Yes No
If yes, please specify the name and address of the organization(s) or individual(s).
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
(If Personal Representative, state relationship to patient)
DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)
DATE
FOR IHS USE ONLY
DATE RECEIVED AMENDMENT HAS BEEN
Accepted Denied
IF DENIED, CHECK REASON FOR DENIAL
IHS did not create record
PHI is not part of the patient’s
designated record set
Record is not available to the patient for
inspection under Federal law
Record is accurate and complete
COMMENTS OF HEALTHCARE PROVIDER (If applicable)
SIGNATURE OF HEALTHCARE PROVIDER (If applicable)
TITLE DATE
SIGNATURE OF CEO OR DESIGNEE DATE
IHS-917 (04/09)
FRONT
PSC Publishing Services (301) 443-6740
EF
Instructions for Completing IHS Form 917 --
Request for Correction/Amendment of Protected Health Information (PHI)
1. Print legibly in all fields using dark permanent ink.
Sign and date the request. 2.
3.
Submit the completed and signed form to the Chief Executive Officer (CEO) or designee.
4.
You will receive a photocopy of your completed form, as an acknowledgement of receipt of your request,
no later than 10 business days after IHS receives your request.
5. You will be notified of the acceptance or denial of your request.
a.
If you are a U.S. citizen or alien lawfully admitted for permanent residence, IHS is required by law to
notify any previous recipient of the record in question of the corrective action taken, if IHS made an
accounting of such disclosure.
b.
Regardless of your citizenship status, IHS will make reasonable efforts to send any amended or
corrected information to anyone who IHS knows received this information in the past and who may have
relied, or is likely to rely, on such information to your detriment.
c.
IHS will make reasonable efforts to send the correction or amendment to those individuals or entities/
organizations you identify and who have a need for the correction or amendment.
6. If you agree to allow IHS to release any amended information and if your request to amend is accepted:
a.
Submit to the Service Unit CEO a one page written statement disagreeing with the denial and the basis
of such disagreement.
If you do not submit a statement of disagreement, you may request that IHS provide this request for
correction or amendment (or summary) and the denial with any future disclosures.
b.
c.
IHS has the right to prepare a written rebuttal to any statement of disagreement. You will be provided a
copy of any rebuttal statement. Any written rebuttal prepared by IHS is not subject to correction or
amendment.
7.
If you are not a U.S. citizen or alien lawfully admitted for permanent residence, and your request is denied,
you may do the following:
a. Appeal the refusal to correct or amend the requested information to the Area Director.
b.
In the event your appeal is ultimately denied, or if you elect not to appeal, you may submit a statement
of disagreement or request as described in 7(a) and 7(b) above.
c.
IHS has the right to prepare a written rebuttal to any statement of disagreement. You will be provided a
copy of any rebuttal statement. Any written rebuttal prepared by IHS is not subject to correction or
amendment.
d. In addition, if your appeal is denied, you may seek judicial review of the decision.
If you are a U.S. citizen or alien lawfully admitted for permanent residence, and your request is denied, you
may do the following:
8.
If you have a complaint about IHS’ policies and procedures regarding health information, you may file such
a complaint with the Service Unit CEO; Department of Health and Human Services, Office for Civil Rights;
or with the Secretary, Department of Health and Human Services, Washington, DC 20201.
9.
10.
This form and subsequent information pertaining to this request will become part of your permanent health
record.
FOR IHS CEO: Insert Service Unit address, CEO’s name & Title, and Telephone # into area below.
OMB STATEMENT
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.
IHS-917 (04/09)
BACK
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FORM APPROVED: OMB NO. 0917-0030: REQUEST FOR CORRECTIONAMENDMENT (Indian Health Service Office of IT)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document