Indian Health Service Purchased/Referred Care Proof of Residency

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form IHS-976 IHS Proof of Residency Form	Form and Instruction	New	Available
OMB ICR Supporting Statement A and B - PRC 3.21.19.docx	Supporting Statement A	Uploaded 2019-03-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234054	IHS Proof of Residency Form	Form and Instruction	New

ICR Details

OMB Control No: 0917-0040	ICR Reference No: 201811-0917-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Indian Health Service Purchased/Referred Care Proof of Residency
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/22/2019
	Date Received in OIRA: 11/23/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved
Responses	77,185	0	0
Time Burden (Hours)	3,859	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The IHS Purchased/Referred Care Program needs this information to certify that the health care services requested and authorized by the IHS have been provided to individuals who documented to meet the eligibility requirements to receive medical services for Purchased/Referred Care provider(s). It is also to serve as a legal document for health and medical care authorized by IHS and rendered by health care providers under contract with the IHS.

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Authorizing Statute(s): PL: Pub.L. 83 - 568 Part 1 Name of Law: Transfer Act
   US Code: 42 USC 136 Name of Law: Indian Health
   US Code: 25 USC 13 Name of Law: Synder Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 13764	03/30/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 48450	09/25/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
IHS Proof of Residency Form	IHS-976	Purchased Referred Care Proof of Residency

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	77,185	0	0	77,185	0	0
Annual Time Burden (Hours)	3,859	0	0	3,859	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection that will provide proof of residency in IHS operating areas. The increase is to collection data for this new collection.

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/23/2018

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