DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR AN ACCOUNTING OF DISCLOSURES
FORM APPROVED: OMB NO. 0917-0030
Expiration Date: 02-29-2020
See OMB Statement below.
DATE OF REQUEST
PATIENT NAME
HEALTH RECORD NUMBER
DATE OF BIRTH
PATIENT ADDRESS
The information is to be disclosed by:
NAME OF FACILITY
ADDRESS
CITY STATE
I would like an accounting of disclosures for the following time frame (e.g., From: 01/01/09 To: 01/30/09)
From: To:
If you are only seeking an accounting of a certain type(s) of disclosure or disclosures to a specific person/
organization, please describe the disclosures for which you are seeking an accounting:
I understand that the accounting will be provided to me within 60 days of the date of this request, unless IHS extends the
time frame for an additional 30 days and provides me with a written statement for the reason(s) for the delay and the date
by which I can expect to receive the accounting.
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 DATE SENT
NAME/TITLE OF IHS EMPLOYEE PROCESSING REQUEST
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-913 (4/09)
PSC Publishing Services (301) 443-6740
EF
