+---+--------+----------------------+---+----------------+---+---+-----------+
| I |        | DEPARTMENT OF HEALTH |   |                | F |   |           |
| H |        | AND HUMAN SERVICES   |   |                | O |   |           |
| S |        |                      |   |                | R |   |           |
| - |        | Indian Health        |   |                | M |   |           |
| 8 |        | Service              |   |                | A |   |           |
| 1 |        |                      |   |                | P |   |           |
| 0 |        |                      |   |                | P |   |           |
| ( |        |                      |   |                | R |   |           |
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| 1 |        |                      |   |                | V |   |           |
| / |        |                      |   |                | E |   |           |
| 0 |        |                      |   |                | D |   |           |
| 6 |        |                      |   |                | : |   |           |
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| F |        |                      |   |                | B |   |           |
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|   |        |                      |   |                | 9 |   |           |
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|   |        |                      |   |                | 2 |   |           |
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|   |        |                      |   |                | 9 |   |           |
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+---+--------+----------------------+---+----------------+---+---+-----------+
| * |        |                      |   |                |   |   |           |
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+---+--------+----------------------+---+----------------+---+---+-----------+
| * |        |                      |   |                |   |   |           |
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| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
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| * |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| * | I,     |                      |   |                |   |   |           |
| * | [      |                      |   |                |   |   |           |
| I |      ] |                      |   |                |   |   |           |
| . | {.unde |                      |   |                |   |   |           |
| * | rline} |                      |   |                |   |   |           |
| * | ,      |                      |   |                |   |   |           |
|   | hereby |                      |   |                |   |   |           |
|   | volun  |                      |   |                |   |   |           |
|   | tarily |                      |   |                |   |   |           |
|   | aut    |                      |   |                |   |   |           |
|   | horize |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | disc   |                      |   |                |   |   |           |
|   | losure |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | from   |                      |   |                |   |   |           |
|   | my     |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | health |                      |   |                |   |   |           |
|   | r      |                      |   |                |   |   |           |
|   | ecord. |                      |   |                |   |   |           |
|   | *(Name |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | Pat    |                      |   |                |   |   |           |
|   | ient)* |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| * | **The  |                      |   | **And is to be |   |   |           |
| * | infor  |                      |   | provided to:** |   |   |           |
| I | mation |                      |   |                |   |   |           |
| I | is to  |                      |   |                |   |   |           |
| . | be     |                      |   |                |   |   |           |
| * | dis    |                      |   |                |   |   |           |
| * | closed |                      |   |                |   |   |           |
|   | by:**  |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   | NAME   |                      |   | NAME OF        |   |   |           |
|   | OF     |                      |   | PERSON/ORGANIZ |   |   |           |
|   | FA     |                      |   | ATION/FACILITY |   |   |           |
|   | CILITY |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   | A      |                      |   | ADDRESS        |   |   |           |
|   | DDRESS |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   | CITY   |                      |   | CITY/STATE     |   |   |           |
|   | /STATE |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| * | **The  |                      |   |                |   |   |           |
| * | p      |                      |   |                |   |   |           |
| I | urpose |                      |   |                |   |   |           |
| I | or     |                      |   |                |   |   |           |
| I | need   |                      |   |                |   |   |           |
| . | for    |                      |   |                |   |   |           |
| * | this   |                      |   |                |   |   |           |
| * | disc   |                      |   |                |   |   |           |
|   | losure |                      |   |                |   |   |           |
|   | is:**  |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | F      |                      |   |                |   |   |           |
|   | urther |                      |   |                |   |   |           |
|   | M      |                      |   |                |   |   |           |
|   | edical |                      |   |                |   |   |           |
|   | Care   |                      |   |                |   |   |           |
|   | At     |                      |   |                |   |   |           |
|   | torney |                      |   |                |   |   |           |
|   | School |                      |   |                |   |   |           |
|   | Re     |                      |   |                |   |   |           |
|   | search |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Pe     |                      |   |                |   |   |           |
|   | rsonal |                      |   |                |   |   |           |
|   | Use    |                      |   |                |   |   |           |
|   | Ins    |                      |   |                |   |   |           |
|   | urance |                      |   |                |   |   |           |
|   | Disa   |                      |   |                |   |   |           |
|   | bility |                      |   |                |   |   |           |
|   | Other  |                      |   |                |   |   |           |
|   | *(Spe  |                      |   |                |   |   |           |
|   | cify)* |                      |   |                |   |   |           |
|   | [      |                      |   |                |   |   |           |
|   |      ] |                      |   |                |   |   |           |
|   | {.unde |                      |   |                |   |   |           |
|   | rline} |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| * | **The  |                      |   |                |   |   |           |
| * | infor  |                      |   |                |   |   |           |
| I | mation |                      |   |                |   |   |           |
| V | to be  |                      |   |                |   |   |           |
| . | dis    |                      |   |                |   |   |           |
| * | closed |                      |   |                |   |   |           |
| * | from   |                      |   |                |   |   |           |
|   | my     |                      |   |                |   |   |           |
|   | health |                      |   |                |   |   |           |
|   | rec    |                      |   |                |   |   |           |
|   | ord:** |                      |   |                |   |   |           |
|   | *      |                      |   |                |   |   |           |
|   | (check |                      |   |                |   |   |           |
|   | appro  |                      |   |                |   |   |           |
|   | priate |                      |   |                |   |   |           |
|   | box    |                      |   |                |   |   |           |
|   | (es))* |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Entire |                      |   |                |   |   |           |
|   | Record |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Only   |                      |   |                |   |   |           |
|   | infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | r      |                      |   |                |   |   |           |
|   | elated |                      |   |                |   |   |           |
|   | to     |                      |   |                |   |   |           |
|   | *(spec |                      |   |                |   |   |           |
|   | ify)*: |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | >      |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   | Only   |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | period |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | events |                      |   |                |   |   |           |
|   | from   |                      |   |                |   |   |           |
|   | [      |                      |   |                |   |   |           |
|   |      ] |                      |   |                |   |   |           |
|   | {.unde |                      |   |                |   |   |           |
|   | rline} |                      |   |                |   |   |           |
|   | to     |                      |   |                |   |   |           |
|   | [      |                      |   |                |   |   |           |
|   |      ] |                      |   |                |   |   |           |
|   | {.unde |                      |   |                |   |   |           |
|   | rline} |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Other  |                      |   |                |   |   |           |
|   | *(spe  |                      |   |                |   |   |           |
|   | cify)* |                      |   |                |   |   |           |
|   | *(CHS, |                      |   |                |   |   |           |
|   | Bi     |                      |   |                |   |   |           |
|   | lling, |                      |   |                |   |   |           |
|   | etc.)* |                      |   |                |   |   |           |
|   | [      |                      |   |                |   |   |           |
|   |      ] |                      |   |                |   |   |           |
|   | {.unde |                      |   |                |   |   |           |
|   | rline} |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | P      |                      |   |                |   |   |           |
|   | sychot |                      |   |                |   |   |           |
|   | herapy |                      |   |                |   |   |           |
|   | Notes  |                      |   |                |   |   |           |
|   | ONLY   |                      |   |                |   |   |           |
|   | (by    |                      |   |                |   |   |           |
|   | ch     |                      |   |                |   |   |           |
|   | ecking |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | box, I |                      |   |                |   |   |           |
|   | am     |                      |   |                |   |   |           |
|   | w      |                      |   |                |   |   |           |
|   | aiving |                      |   |                |   |   |           |
|   | any    |                      |   |                |   |   |           |
|   | psych  |                      |   |                |   |   |           |
|   | othera |                      |   |                |   |   |           |
|   | pist-p |                      |   |                |   |   |           |
|   | atient |                      |   |                |   |   |           |
|   | priv   |                      |   |                |   |   |           |
|   | ilege) |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | **If   |                      |   |                |   |   |           |
|   | you    |                      |   |                |   |   |           |
|   | would  |                      |   |                |   |   |           |
|   | like   |                      |   |                |   |   |           |
|   | any of |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | fol    |                      |   |                |   |   |           |
|   | lowing |                      |   |                |   |   |           |
|   | sen    |                      |   |                |   |   |           |
|   | sitive |                      |   |                |   |   |           |
|   | infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | disc   |                      |   |                |   |   |           |
|   | losed, |                      |   |                |   |   |           |
|   | check  |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | appl   |                      |   |                |   |   |           |
|   | icable |                      |   |                |   |   |           |
|   | b      |                      |   |                |   |   |           |
|   | ox(es) |                      |   |                |   |   |           |
|   | be     |                      |   |                |   |   |           |
|   | low:** |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Alcoho |                      |   |                |   |   |           |
|   | l/Drug |                      |   |                |   |   |           |
|   | Abuse  |                      |   |                |   |   |           |
|   | Treatm |                      |   |                |   |   |           |
|   | ent/Re |                      |   |                |   |   |           |
|   | ferral |                      |   |                |   |   |           |
|   | HIV/   |                      |   |                |   |   |           |
|   | AIDS-r |                      |   |                |   |   |           |
|   | elated |                      |   |                |   |   |           |
|   | Tre    |                      |   |                |   |   |           |
|   | atment |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | Se     |                      |   |                |   |   |           |
|   | xually |                      |   |                |   |   |           |
|   | Trans  |                      |   |                |   |   |           |
|   | mitted |                      |   |                |   |   |           |
|   | Di     |                      |   |                |   |   |           |
|   | seases |                      |   |                |   |   |           |
|   | Mental |                      |   |                |   |   |           |
|   | Health |                      |   |                |   |   |           |
|   | *      |                      |   |                |   |   |           |
|   | (Other |                      |   |                |   |   |           |
|   | than   |                      |   |                |   |   |           |
|   | P      |                      |   |                |   |   |           |
|   | sychot |                      |   |                |   |   |           |
|   | herapy |                      |   |                |   |   |           |
|   | N      |                      |   |                |   |   |           |
|   | otes)* |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| * | I      |                      |   |                |   |   |           |
| * | unde   |                      |   |                |   |   |           |
| V | rstand |                      |   |                |   |   |           |
| . | that I |                      |   |                |   |   |           |
| * | may    |                      |   |                |   |   |           |
| * | revoke |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | uthori |                      |   |                |   |   |           |
|   | zation |                      |   |                |   |   |           |
|   | in     |                      |   |                |   |   |           |
|   | w      |                      |   |                |   |   |           |
|   | riting |                      |   |                |   |   |           |
|   | sub    |                      |   |                |   |   |           |
|   | mitted |                      |   |                |   |   |           |
|   | at any |                      |   |                |   |   |           |
|   | time   |                      |   |                |   |   |           |
|   | to the |                      |   |                |   |   |           |
|   | Health |                      |   |                |   |   |           |
|   | Infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | Mana   |                      |   |                |   |   |           |
|   | gement |                      |   |                |   |   |           |
|   | (      |                      |   |                |   |   |           |
|   | Health |                      |   |                |   |   |           |
|   | Re     |                      |   |                |   |   |           |
|   | cords) |                      |   |                |   |   |           |
|   | Depar  |                      |   |                |   |   |           |
|   | tment, |                      |   |                |   |   |           |
|   | except |                      |   |                |   |   |           |
|   | to the |                      |   |                |   |   |           |
|   | extent |                      |   |                |   |   |           |
|   | that   |                      |   |                |   |   |           |
|   | action |                      |   |                |   |   |           |
|   | has    |                      |   |                |   |   |           |
|   | been   |                      |   |                |   |   |           |
|   | taken  |                      |   |                |   |   |           |
|   | in     |                      |   |                |   |   |           |
|   | re     |                      |   |                |   |   |           |
|   | liance |                      |   |                |   |   |           |
|   | on     |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | au     |                      |   |                |   |   |           |
|   | thoriz |                      |   |                |   |   |           |
|   | ation. |                      |   |                |   |   |           |
|   | If     |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | uthori |                      |   |                |   |   |           |
|   | zation |                      |   |                |   |   |           |
|   | was    |                      |   |                |   |   |           |
|   | ob     |                      |   |                |   |   |           |
|   | tained |                      |   |                |   |   |           |
|   | as a   |                      |   |                |   |   |           |
|   | con    |                      |   |                |   |   |           |
|   | dition |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | obt    |                      |   |                |   |   |           |
|   | aining |                      |   |                |   |   |           |
|   | ins    |                      |   |                |   |   |           |
|   | urance |                      |   |                |   |   |           |
|   | co     |                      |   |                |   |   |           |
|   | verage |                      |   |                |   |   |           |
|   | or a   |                      |   |                |   |   |           |
|   | policy |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | insu   |                      |   |                |   |   |           |
|   | rance, |                      |   |                |   |   |           |
|   | other  |                      |   |                |   |   |           |
|   | law    |                      |   |                |   |   |           |
|   | may    |                      |   |                |   |   |           |
|   | p      |                      |   |                |   |   |           |
|   | rovide |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | i      |                      |   |                |   |   |           |
|   | nsurer |                      |   |                |   |   |           |
|   | with   |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | right  |                      |   |                |   |   |           |
|   | to     |                      |   |                |   |   |           |
|   | c      |                      |   |                |   |   |           |
|   | ontest |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | claim  |                      |   |                |   |   |           |
|   | under  |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | p      |                      |   |                |   |   |           |
|   | olicy. |                      |   |                |   |   |           |
|   | If     |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | uthori |                      |   |                |   |   |           |
|   | zation |                      |   |                |   |   |           |
|   | has    |                      |   |                |   |   |           |
|   | not    |                      |   |                |   |   |           |
|   | been   |                      |   |                |   |   |           |
|   | re     |                      |   |                |   |   |           |
|   | voked, |                      |   |                |   |   |           |
|   | it     |                      |   |                |   |   |           |
|   | will   |                      |   |                |   |   |           |
|   | ter    |                      |   |                |   |   |           |
|   | minate |                      |   |                |   |   |           |
|   | one    |                      |   |                |   |   |           |
|   | year   |                      |   |                |   |   |           |
|   | from   |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | date   |                      |   |                |   |   |           |
|   | of my  |                      |   |                |   |   |           |
|   | sig    |                      |   |                |   |   |           |
|   | nature |                      |   |                |   |   |           |
|   | unless |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | dif    |                      |   |                |   |   |           |
|   | ferent |                      |   |                |   |   |           |
|   | expi   |                      |   |                |   |   |           |
|   | ration |                      |   |                |   |   |           |
|   | date   |                      |   |                |   |   |           |
|   | or     |                      |   |                |   |   |           |
|   | *expi  |                      |   |                |   |   |           |
|   | ration |                      |   |                |   |   |           |
|   | event* |                      |   |                |   |   |           |
|   | is     |                      |   |                |   |   |           |
|   | s      |                      |   |                |   |   |           |
|   | tated. |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | [      |                      |   |                |   |   |           |
|   |      ] |                      |   |                |   |   |           |
|   | {.unde |                      |   |                |   |   |           |
|   | rline} |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | *      |                      |   |                |   |   |           |
|   | (Enter |                      |   |                |   |   |           |
|   | if     |                      |   |                |   |   |           |
|   | dif    |                      |   |                |   |   |           |
|   | ferent |                      |   |                |   |   |           |
|   | from   |                      |   |                |   |   |           |
|   | **one  |                      |   |                |   |   |           |
|   | year   |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | fter** |                      |   |                |   |   |           |
|   | date   |                      |   |                |   |   |           |
|   | b      |                      |   |                |   |   |           |
|   | elow)* |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | I      |                      |   |                |   |   |           |
|   | unde   |                      |   |                |   |   |           |
|   | rstand |                      |   |                |   |   |           |
|   | that   |                      |   |                |   |   |           |
|   | IHS    |                      |   |                |   |   |           |
|   | will   |                      |   |                |   |   |           |
|   | not    |                      |   |                |   |   |           |
|   | con    |                      |   |                |   |   |           |
|   | dition |                      |   |                |   |   |           |
|   | tre    |                      |   |                |   |   |           |
|   | atment |                      |   |                |   |   |           |
|   | or     |                      |   |                |   |   |           |
|   | eligi  |                      |   |                |   |   |           |
|   | bility |                      |   |                |   |   |           |
|   | for    |                      |   |                |   |   |           |
|   | care   |                      |   |                |   |   |           |
|   | on my  |                      |   |                |   |   |           |
|   | pro    |                      |   |                |   |   |           |
|   | viding |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | a      |                      |   |                |   |   |           |
|   | uthori |                      |   |                |   |   |           |
|   | zation |                      |   |                |   |   |           |
|   | except |                      |   |                |   |   |           |
|   | if     |                      |   |                |   |   |           |
|   | such   |                      |   |                |   |   |           |
|   | care   |                      |   |                |   |   |           |
|   | is:    |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | \(1\)  |                      |   |                |   |   |           |
|   | re     |                      |   |                |   |   |           |
|   | search |                      |   |                |   |   |           |
|   | r      |                      |   |                |   |   |           |
|   | elated |                      |   |                |   |   |           |
|   | or (2) |                      |   |                |   |   |           |
|   | pr     |                      |   |                |   |   |           |
|   | ovided |                      |   |                |   |   |           |
|   | solely |                      |   |                |   |   |           |
|   | for    |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | p      |                      |   |                |   |   |           |
|   | urpose |                      |   |                |   |   |           |
|   | of     |                      |   |                |   |   |           |
|   | cr     |                      |   |                |   |   |           |
|   | eating |                      |   |                |   |   |           |
|   | Pro    |                      |   |                |   |   |           |
|   | tected |                      |   |                |   |   |           |
|   | Health |                      |   |                |   |   |           |
|   | Infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | for    |                      |   |                |   |   |           |
|   | disc   |                      |   |                |   |   |           |
|   | losure |                      |   |                |   |   |           |
|   | to a   |                      |   |                |   |   |           |
|   | third  |                      |   |                |   |   |           |
|   | party. |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   | I      |                      |   |                |   |   |           |
|   | unde   |                      |   |                |   |   |           |
|   | rstand |                      |   |                |   |   |           |
|   | that   |                      |   |                |   |   |           |
|   | infor  |                      |   |                |   |   |           |
|   | mation |                      |   |                |   |   |           |
|   | dis    |                      |   |                |   |   |           |
|   | closed |                      |   |                |   |   |           |
|   | by     |                      |   |                |   |   |           |
|   | this   |                      |   |                |   |   |           |
|   | au     |                      |   |                |   |   |           |
|   | thoriz |                      |   |                |   |   |           |
|   | ation, |                      |   |                |   |   |           |
|   | except |                      |   |                |   |   |           |
|   | for    |                      |   |                |   |   |           |
|   | A      |                      |   |                |   |   |           |
|   | lcohol |                      |   |                |   |   |           |
|   | and    |                      |   |                |   |   |           |
|   | Drug   |                      |   |                |   |   |           |
|   | Abuse  |                      |   |                |   |   |           |
|   | as     |                      |   |                |   |   |           |
|   | d      |                      |   |                |   |   |           |
|   | efined |                      |   |                |   |   |           |
|   | in 42  |                      |   |                |   |   |           |
|   | CFR    |                      |   |                |   |   |           |
|   | Part   |                      |   |                |   |   |           |
|   | 2, may |                      |   |                |   |   |           |
|   | be     |                      |   |                |   |   |           |
|   | s      |                      |   |                |   |   |           |
|   | ubject |                      |   |                |   |   |           |
|   | to     |                      |   |                |   |   |           |
|   | redisc |                      |   |                |   |   |           |
|   | losure |                      |   |                |   |   |           |
|   | by the |                      |   |                |   |   |           |
|   | rec    |                      |   |                |   |   |           |
|   | ipient |                      |   |                |   |   |           |
|   | and    |                      |   |                |   |   |           |
|   | may no |                      |   |                |   |   |           |
|   | longer |                      |   |                |   |   |           |
|   | be     |                      |   |                |   |   |           |
|   | pro    |                      |   |                |   |   |           |
|   | tected |                      |   |                |   |   |           |
|   | by the |                      |   |                |   |   |           |
|   | Health |                      |   |                |   |   |           |
|   | Ins    |                      |   |                |   |   |           |
|   | urance |                      |   |                |   |   |           |
|   | Porta  |                      |   |                |   |   |           |
|   | bility |                      |   |                |   |   |           |
|   | and    |                      |   |                |   |   |           |
|   | Ac     |                      |   |                |   |   |           |
|   | counta |                      |   |                |   |   |           |
|   | bility |                      |   |                |   |   |           |
|   | Act    |                      |   |                |   |   |           |
|   | P      |                      |   |                |   |   |           |
|   | rivacy |                      |   |                |   |   |           |
|   | Rule   |                      |   |                |   |   |           |
|   | \[45   |                      |   |                |   |   |           |
|   | CFR    |                      |   |                |   |   |           |
|   | Part   |                      |   |                |   |   |           |
|   | 164\]  |                      |   |                |   |   |           |
|   | , and  |                      |   |                |   |   |           |
|   | the    |                      |   |                |   |   |           |
|   | P      |                      |   |                |   |   |           |
|   | rivacy |                      |   |                |   |   |           |
|   | Act of |                      |   |                |   |   |           |
|   | 1974   |                      |   |                |   |   |           |
|   | \[5    |                      |   |                |   |   |           |
|   | USC    |                      |   |                |   |   |           |
|   | 5      |                      |   |                |   |   |           |
|   | 52a\]. |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| S |        |                      |   |                |   |   | DATE      |
| I |        |                      |   |                |   |   |           |
| G |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| U |        |                      |   |                |   |   |           |
| R |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| O |        |                      |   |                |   |   |           |
| F |        |                      |   |                |   |   |           |
| P |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| S |        |                      |   |                |   |   | DATE      |
| I |        |                      |   |                |   |   |           |
| G |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| U |        |                      |   |                |   |   |           |
| R |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| O |        |                      |   |                |   |   |           |
| F |        |                      |   |                |   |   |           |
| P |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| R |        |                      |   |                |   |   |           |
| S |        |                      |   |                |   |   |           |
| O |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| L |        |                      |   |                |   |   |           |
| R |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| P |        |                      |   |                |   |   |           |
| R |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| S |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| V |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| * |        |                      |   |                |   |   |           |
| ( |        |                      |   |                |   |   |           |
| S |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| ) |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| W |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| ( |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| g |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| k |        |                      |   |                |   |   |           |
| ) |        |                      |   |                |   |   |           |
| * |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| T |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| v |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| c |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| . |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| w |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| k |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| w |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| g |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| w |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| q |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| c |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| c |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| c |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| g |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| v |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| F |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| g |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| c |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| p |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| h |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| b |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| g |        |                      |   |                |   |   |           |
| u |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| l |        |                      |   |                |   |   |           |
| t |        |                      |   |                |   |   |           |
| y |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| f |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| s |        |                      |   |                |   |   |           |
| d |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| m |        |                      |   |                |   |   |           |
| e |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| n |        |                      |   |                |   |   |           |
| o |        |                      |   |                |   |   |           |
| r |        |                      |   |                |   |   |           |
| ( |        |                      |   |                |   |   |           |
| 5 |        |                      |   |                |   |   |           |
| U |        |                      |   |                |   |   |           |
| S |        |                      |   |                |   |   |           |
| C |        |                      |   |                |   |   |           |
| 5 |        |                      |   |                |   |   |           |
| 5 |        |                      |   |                |   |   |           |
| 2 |        |                      |   |                |   |   |           |
| a |        |                      |   |                |   |   |           |
| ( |        |                      |   |                |   |   |           |
| i |        |                      |   |                |   |   |           |
| ) |        |                      |   |                |   |   |           |
| ( |        |                      |   |                |   |   |           |
| 3 |        |                      |   |                |   |   |           |
| ) |        |                      |   |                |   |   |           |
| ) |        |                      |   |                |   |   |           |
| . |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
| > |        |                      |   | NAME *(Last,   |   | R |           |
|   |        |                      |   | First, MI)*    |   | E |           |
| * |        |                      |   |                |   | C |           |
| * |        |                      |   |                |   | O |           |
| P |        |                      |   |                |   | R |           |
| A |        |                      |   |                |   | D |           |
| T |        |                      |   |                |   | N |           |
| I |        |                      |   |                |   | U |           |
| E |        |                      |   |                |   | M |           |
| N |        |                      |   |                |   | B |           |
| T |        |                      |   |                |   | E |           |
| > |        |                      |   |                |   | R |           |
|   |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| D |        |                      |   |                |   |   |           |
| E |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| F |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| C |        |                      |   |                |   |   |           |
| A |        |                      |   |                |   |   |           |
| T |        |                      |   |                |   |   |           |
| I |        |                      |   |                |   |   |           |
| O |        |                      |   |                |   |   |           |
| N |        |                      |   |                |   |   |           |
| * |        |                      |   |                |   |   |           |
| * |        |                      |   |                |   |   |           |
| > |        |                      |   |                |   |   |           |
| > |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   |        |                      |   | ADDRESS        |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+
|   |        |                      |   | CITY/STATE     |   | D |           |
|   |        |                      |   |                |   | A |           |
|   |        |                      |   |                |   | T |           |
|   |        |                      |   |                |   | E |           |
|   |        |                      |   |                |   | O |           |
|   |        |                      |   |                |   | F |           |
|   |        |                      |   |                |   | B |           |
|   |        |                      |   |                |   | I |           |
|   |        |                      |   |                |   | R |           |
|   |        |                      |   |                |   | T |           |
|   |        |                      |   |                |   | H |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
|   |        |                      |   |                |   |   |           |
+---+--------+----------------------+---+----------------+---+---+-----------+

HIS-810 (11/06)

BACK

**Instructions for Completing IHS Form 810 \--\
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION**

> 1\. Print legibly in all fields using dark ink.
>
> 2\. Section I, print name of patient whose information is to be
> released.
>
> 3\. Section II, print the name and address of the facility releasing
> the information. Also, provide the name of the person, facility and
> address that will receive the information.
>
> 4\. Section III, state the reason why the information is needed, e.g.,
> disability claim, continuing medical care, legal, research related
> projects, etc.
>
> 5\. Section IV, check the appropriate box as applicable.
>
> a\. **Entire Record** -- the complete record except for the sensitive
> information (alcohol and drug abuse treatment/referral, sexually
> transmitted diseases, HIV/AIDS related treatment, and mental health
> other than psychotherapy notes)
>
> b\. **Only information related to** -- specify diagnosis, injury,
> operations, special therapies, etc.
>
> c\. **Only the period of events from** -- specify date range, e.g.,
> Jan. 1,2002 to Feb. 1, 2002.
>
> d\. **Other *(specify)*** \-- e.g., CHS, billing, employee health
>
> e\. **Psychotherapy Notes ONLY \-- IN ORDER TO AUTHORIZE THE USE OR
> DISCLOSURE OF PSYCHOTHERAPY NOTES, ONLY THIS BOX SHOULD BE CHECKED ON
> THIS FORM. AUTHORIZATIONS FOR THE USE OR DISCLOSURE OF OTHER HEALTH
> RECORD\
> INFORMATION MAY NOT BE MADE IN CONJUNCTION WITH AUTHORIZATIONS
> PERTAINING TO PSYCHOTHERAPY NOTES.**
>
> IF THIS BOX IS CHECKED WITH OTHER BOXES, ANOTHER AUTHORIZATION WILL BE
> REQUIRED TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES
> ONLY.
>
> Psychotherapy notes are often referred to as process notes,
> distinguishable from progress notes in the medical record. These notes
> capture the therapist's impressions about the patient, contain details
> of the psychotherapy conversation considered to be inappropriate for
> the medical record, and are used by the provider for future sessions.
> These notes are often kept separate to limit access because they
> contain sensitive information relevant to no one other than the
> treating provider.
>
> f\. **IN ORDER TO RELEASE SENSITIVE INFORMATION, ALCOHOL/DRUG ABUSE
> TREATMENT/ REFERRAL, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED
> DISEASES, MENTAL HEALTH (OTHER THAN PSYCHOTHERAPY NOTES), THE
> APPROPRIATE BOX [MUST]{.underline} BE CHECKED BY THE PATIENT.**
>
> 6\. Section V, Patient [must]{.underline} sign and date. If a
> different *expiration* date is desired, specify a new date.
>
> 7\. Section V, Personal Representative, e.g., legal guardian, power of
> attorney, etc.
>
> 8\. A copy of the completed Form IHS-810 will be given to the patient.

OMB STATEMENT

Public reporting burden for this collection of information is estimated
to average 20 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.