IHS Form 810, officially the Authorization for Use or Disclosure of Protected Health Information, is the paper you sign to let an Indian Health Service facility share your medical records with someone outside IHS. You’ll fill it out any time your records need to move: a referral to an outside specialist, a Social Security disability claim, a lawyer’s request, a school health file, or a copy for yourself. The form is a free PDF on the IHS Patient Forms page and is stocked at every IHS clinic’s Health Information Management (HIM) department.1Indian Health Service. Patient Forms The current version carries OMB approval 0917-0030 and expires December 31, 2026.2Department of Health and Human Services. IHS-810 Authorization for Use or Disclosure of Protected Health Information
IHS records sit under both the HIPAA Privacy Rule and the federal Privacy Act of 1974, so the facility cannot release your information to an outside party without your written permission. Form 810 is that permission. It is not a payment form and not a PRC authorization; if you’re being referred through Purchased/Referred Care, the PRC office handles payment separately, and Form 810 only moves the medical records.
Before You Start
Use dark permanent ink and print clearly. If you’ve been seen at more than one IHS facility and need records from each, you’ll need a separate Form 810 for every facility. Leaving any section blank will delay processing.
Filling Out the Six Sections
Section I: Authorization Statement
Print the patient’s full name. If you’re a parent or legal representative signing for someone else, print the patient’s name here, not your own.
Section II: Who Is Releasing the Records
Name and address of the IHS facility that holds the records. This is where you were treated, not where the records are going.
Section III: Who Receives the Records
Full name and address of the person, office, or facility that will get the records. Be specific: “my lawyer” is not enough for HIM staff to act on. If the disclosure is meant to prevent multiple enrollments in a substance use treatment program, the form’s instructions require you to list each program by name or write “any withdrawal management or maintenance treatment program within 200 miles” of the releasing facility.
Section IV: Purpose
Check the box that matches why you need the records released. The choices on the form are:
- Treatment, Payment, or Other Healthcare Operations — the usual choice for a PRC referral or outside provider handoff
- Disability — for Social Security or tribal disability claims
- Attorney — personal injury, workers’ compensation, custody
- Personal Use — a copy for yourself
- School — enrollment or accommodation documentation
- Research — approved studies
- Health Information Exchange — sharing with other providers through an electronic exchange
- Other
If you check “Other” or “Health Information Exchange (non-IHS),” write in the detail. For an HIE, include the exchange’s name and describe which providers can access the records, for example “my current and future treating providers.”
Section V: What Information Gets Released
This section controls scope. Pick one of four options:
- Only information related to a specific diagnosis, injury, surgery, or therapy that you write in
- Only the period of events from one date to another that you write in
- Other — write in a category like “Purchased Referred Care,” “Billing,” or “Employee Health”
- Entire Record — everything in your file
Match the scope to the recipient’s need. Too narrow and the recipient can’t do their job; “Entire Record” hands over everything.
Section VI: Signature, Date, Expiration, and Patient ID
Sign and date the form. A personal representative signing on the patient’s behalf must also state their authority, such as “parent” or “legal guardian.” A signature made by thumbprint or mark requires a witness signature. Complete the Patient Identification block with last name, first name, middle initial, address, date of birth, and IHS record number.
Expiration works like this: the authorization ends one year from the signature date unless you write in a different date or event. For health information exchange opt-ins, IHS recommends a five-year expiration to keep continuity of care intact. For court-ordered substance use disorder disclosures, the expiration cannot go past the final disposition of the criminal proceeding.
Sensitive Categories and the Psychotherapy Notes Rule
Some categories of health information have extra federal protection, and IHS will not release them even if you check “Entire Record” unless you also check the specific box for that category. The form lists them separately in Section V:
- Substance Use Disorder Treatment/Referral, protected under 42 CFR Part 2
- HIV/AIDS-Related Treatment
- Mental Health (other than psychotherapy notes)
- Sexually Transmitted Diseases
Psychotherapy notes are handled under their own rule. Federal regulations at 45 CFR 164.508 prohibit combining an authorization for psychotherapy notes with an authorization for any other type of health information on the same form. If you need psychotherapy notes released, check only the “Psychotherapy Notes ONLY” box and leave every other box in Section V unchecked. If you also need other records released, fill out a second Form 810 for those. Checking the psychotherapy notes box alongside other boxes invalidates the psychotherapy portion, and you’ll be asked to start over.
Revoking or Changing Your Authorization
You can cancel a Form 810 authorization at any time by sending a written revocation to the HIM department at the IHS facility that holds your records. The revocation takes effect when the facility receives it, but it doesn’t undo disclosures that already happened while the authorization was in force.
A warning on the form itself is worth reading closely: once your records leave the IHS facility, they may no longer be protected by HIPAA or the Privacy Act. The recipient is bound by whatever privacy rules apply to them, which may offer less protection than the federal standards covering IHS. The one exception is substance use disorder records released under 42 CFR Part 2, which carry a prohibition against redisclosure that travels with the records.
IHS cannot refuse to treat you or deny eligibility for care based on whether you sign Form 810. The form says so, and 45 CFR 164.508 backs it up as a general HIPAA requirement.
Where to Submit the Completed Form
Turn the completed form in to the Health Information Management department at the IHS facility named in Section II. HIM staff process the release and send records to the recipient named in Section III. If you’re filling the form out as part of a Purchased/Referred Care referral, the PRC clerk at your facility can walk you through which boxes to check and what scope of records the outside provider will actually need. Processing time varies by facility, so ask HIM for a turnaround estimate when you submit.
What Form 810 Does Not Do
Form 810 authorizes the movement of medical information. It does not authorize payment for outside care. If your IHS provider is referring you to a specialist or hospital through Purchased/Referred Care, PRC handles the payment authorization through its own referral and purchase order process, separately from the records release you sign here. A signed Form 810 by itself does not obligate PRC or IHS to pay any outside bill.