DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR REVOCATION OF RESTRICTION(S)
FORM APPROVED: OMB NO. 0917-0030
Expiration Date: 02-29-2020
See OMB Statement below.
I hereby revoke the following restriction(s) except to the extent that IHS has already taken action in reliance thereon:
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
IHS is revoking the following restriction(s):
SIGNATURE OF CEO OR DESIGNEE DATE
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.
PATIENT IDENTIFICATION
NAME (Last, First, MI)
RECORD NUMBER
ADDRESS
CITY/STATE
DATE OF BIRTH
IHS-912-2 (4/09)
PSC Publishing Services (301) 443-6740
EF
