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DEPARTMENT OF HEALTH AND HUMAN SERVICES Indian Health Service FORM APPROVED: OMB NO. 09170030 Expiration Date: 09302023 See OMB Statement on Reverse. AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED
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Use of OMB s RequiredPolicy Topics template instructions

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OMB forms are official documents used by federal agencies to collect information from the public, ensuring compliance with the Paperwork Reduction Act.
Entities or individuals that are subject to federal regulations requiring data submission or public reporting must file OMB forms.
To fill out OMB forms, follow the provided instructions carefully, complete all required fields, and submit the form by the designated method outlined by the agency.
The purpose of OMB forms is to standardize information collection across federal agencies, streamline the reporting process, and ensure that data is gathered efficiently.
The information required can vary by form but generally includes personal or organizational identification, relevant data or responses to specific questions, and any required supporting documentation.
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