Information Collection

Order for Health Services

IC 6559 under ICR 201001-0917-002 · OMB 0917-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS-843-1A Order for Health Services	Form and Instruction
IHS-843-1A Order for Health Services IHS-843-1A -Order for Health Services-Rev-June2009.pdf	Form and Instruction

IC Title:

Order for Health Services

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 136.24

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	IHS-843-1A	Order for Health Services	IHS-843-1A -Order for Health Services-Rev-June2009.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,424

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	378,624	67,866	310,758
Annual IC Time Burden (Hours)	18,931	3,393	15,538
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.