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 (4/09)
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