Information Collection

IHS Proof of Residency Form

IC 234054 under ICR 202201-0917-003 · OMB 0917-0040.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS-976 IHS Proof of Residency Form	Form and Instruction
IHS-976 Purchased Referred Care Proof of Residency Final PRC Proof of Residency - 03-21-2019 clean.docx	Form and Instruction
IHS-976 Purchased Referred Care Proof of Residency Final PRC Proof of Residency - 03-21-2019 clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

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-976	Purchased Referred Care Proof of Residency	Final PRC Proof of Residency - 03-21-2019 clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medical, Health, and Billing Records System

FR Citation: 83 FR 6591

Number of Respondents: 77,185

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	77,185	77,185
Annual IC Time Burden (Hours)	3,859	3,859
Annual IC Cost Burden (Dollars)	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.