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<col style="width: 10%" />
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<col style="width: 1%" />
<col style="width: 7%" />
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<tbody>
<tr class="odd">
<td colspan="2">IHS-917 (11/06) FRONT</td>
<td colspan="6"><p>DEPARTMENT OF HEALTH AND HUMAN SERVICES</p>
<p>Indian Health Service</p></td>
<td colspan="2"><p>FORM APPROVED: OMB NO. 0917-0030 Expiration Date:
11/30/2009</p>
<p><em>See OMB Statement on Reverse.</em></p></td>
</tr>
<tr class="even">
<td colspan="10"><h3
id="request-for-correctionamendment-of-protected-health-information">REQUEST
FOR CORRECTION/AMENDMENT OF PROTECTED HEALTH INFORMATION</h3>
<p>5 U.S.C. 522a(d) and 45 CFR 164.526</p></td>
</tr>
<tr class="odd">
<td colspan="4"><p>PATIENT NAME</p>
<p>     </p></td>
<td colspan="3"><p>DATE OF BIRTH</p>
<p>     </p></td>
<td colspan="3"><p>PATIENT RECORD NUMBER</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"><p>PATIENT ADDRESS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="6"><p>DATE OF ENTRY TO BE CORRECTED/AMENDED</p>
<p>     </p></td>
<td colspan="4"><p>INFORMATION TO BE CORRECTED/AMENDED</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"><p>Please explain how the entry is incorrect or
incomplete. What should the entry say to be more accurate or
complete?</p>
<p>Use additional sheets if needed and attach to this form.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>IHS will make reasonable efforts to provide the
amendment to other persons who IHS knows received the<br />
information in the past and who may have relied, or are likely to rely,
on such information in a manner that may be<br />
detrimental to your health care.</p>
<blockquote>
<p> I agree to allow IHS to release any amended information to
individuals or entities as described above.</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="10">Would you like this amendment sent to anyone else who
received the information in the past?</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9"> Yes No If yes, please specify the name and address of
the organization(s) or individual(s) below.</td>
</tr>
<tr class="even">
<td colspan="10"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="9"><p>SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE</p>
<p><em>(If Personal Representative, state relationship to patient) or
Witness (if signature is thumbprint or mark)</em></p></td>
<td><p>DATE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="10"><p id="for-ihs-use-only" class="heading">FOR IHS USE
ONLY</p></td>
</tr>
<tr class="even">
<td colspan="3"><p>DATE RECEIVED</p>
<p>     </p></td>
<td colspan="7"><p>AMENDMENT HAS BEEN</p>
<p> Accepted Denied</p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>IF DENIED, CHECK REASON FOR DENIAL</p>
<blockquote>
<p> PHI is not part of the patient’s designated record set</p>
<p> IHS did not create record</p>
<p> Record is not available to the patient for inspection under federal
law</p>
<p> Record is accurate and complete</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="9">SIGNATURE OF CEO OR DESIGNEE</td>
<td><p>DATE</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>COMMENTS OF HEALTHCARE PROVIDER <em>(If
applicable)</em></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5">SIGNATURE OF HEALTHCARE PROVIDER <em>(If
applicable)</em></td>
<td colspan="4"><p>TITLE</p>
<p>     </p></td>
<td><p>DATE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

IHS-917 (11/06) BACK

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.
>
> 2\. Sign and date the request.
>
> 3\. Submit the completed and signed form to the Chief Executive
> Officer (CEO).
>
> 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.
>
> 6\. If your request is accepted, IHS will follow its policy for
> amendment or correction of health information by\
> informing you and notifying others. 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. In
> addition, regardless of your citizenship\
> status, subject to your agreement 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. IHS will also
> 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.
>
> 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\. Submit to the Service Unit CEO a one page written statement
> disagreeing with the denial and the basis\
> of such disagreement.
>
> b\. 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.
>
> 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.
>
> 8\. If you are a U.S. citizen or alien lawfully admitted for permanent
> residence, you may appeal the refusal to\
> correct or amend the requested information to the Area Director. 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. In addition, if your appeal is denied, you may
> seek judicial review of the decision.
>
> 9\. If you have a complaint about IHS' policies and procedures
> regarding health information, you may file such\
> a complaint with the Service Unit CEO; Office for Civil Rights; or
> with the Secretary, Department of Health\
> and Human Services, Washington, DC 20201.
>
> FOR IHS CEO: Insert Service Unit address, CEO's name & Title, and
> Telephone \# into area below.

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> 10\. This form and subsequent information pertaining to this request
> will become part of your permanent health\
> record.

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  OMB STATEMENT: Public reporting burden for this collection of
  information is estimated to average 15 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, 801 Thompson Ave., TMP Suite 450, Rockville, MD
  20852, RE: PRA 0917-0030. Please DO NOT SEND this form to this address.

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