Indian Health Service Medical Staff Credentials Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0009 Peer Reference Verification	Form and Instruction	New	Repair queued
Form 0917-0009 Malpractice Verification	Form and Instruction	New	Repair queued
Form 0917-0009 Education Verification	Form and Instruction	New	Repair queued
Form 0917-0009 Affiliation Verification	Form and Instruction	New	Repair queued
Form 0917-0009 Credentialing by Proxy Intake Form	Form and Instruction	New	Missing upstream
Form 0917-0009 Reappointment Application	Form and Instruction	New	Repair queued
Form 0917-0009 Indian Health Service Statement of Health	Form and Instruction	New	Missing upstream
Form 0917-0009 Initial Application	Form and Instruction	New	Repair queued
Form 0917-0009 Indian Health Service (IHS) Conditions of Application and Release	Form and Instruction	New	Repair queued
Form 0917-0009 Pre-Application MD APP	Form and Instruction	New	Repair queued
Form 0917-0009 Reappointment Application	Form and Instruction	Removed	Repair queued
Form 0917-0009 Initial Application to Medical Staff with Signature Documents	Form and Instruction	Removed	Repair queued
OMB 0917-0009 Supporting Statement - FINAL 7.31.23.docx	Supporting Statement A	Uploaded 2023-07-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
261342	Peer Reference Verification	Form and Instruction	New
261341	Malpractice Verification	Form and Instruction	New
261340	Education Verification	Form and Instruction	New
261339	Affiliation Verification	Form and Instruction	New
261338	Credentialing by Proxy Intake Form	Form and Instruction	New
261337	Reappointment Application	Form and Instruction	New
261336	Indian Health Service Statement of Health	Form and Instruction	New
261335	Initial Application	Form and Instruction	New
261331	Indian Health Service (IHS) Conditions of Application and Release	Form and Instruction	New
261326	Pre-Application MD APP	Form and Instruction	New
240118	Reappointment Application	Form and Instruction	Removed
240117	Initial Application to Medical Staff with Signature Documents	Form and Instruction	Removed

ICR Details

OMB Control No: 0917-0009	ICR Reference No: 202307-0917-001
Status: Received in OIRA	Previous ICR Reference No: 202002-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No: 18529
Title: Indian Health Service Medical Staff Credentials Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/01/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2023
Responses	24,787	2,700
Time Burden (Hours)	6,747	1,400
Cost Burden (Dollars)	0	0

---

Abstract: This collection of information is used to evaluate individual health care providers applying for medical staff credentials at IHS health care facilities. Provider credentialing in the IHS has been identified as a priority area for quality improvement to support patient safety and demonstrate quality of care. IHS health care facilities require all medical staff applicants to provide information concerning their education, training, licensure, and work experience and any adverse disciplinary actions taken against them. The IHS is transforming credentialing into a centrally installed, automated, standardized, electronic/digital, measurable, portable, accessible, and efficient business process to improve the effectiveness of application and re-application to Medical Staffs, movement of practitioners within the IHS system, and recruitment/retention of high-quality practitioners.

---

Authorizing Statute(s): US Code: 25 USC 450 Name of Law: Indian Self-Determination and Education Act
   US Code: 25 USC 13 Name of Law: Synder Act
   US Code: 42 USC 2001-2004 Name of Law: IHS Transfer Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 30317	05/11/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 48896	07/28/2023
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Affiliation Verification	0917-0009	Affiliation Verification
Credentialing by Proxy Intake Form	0917-0009	Cred by Proxy
Education Verification	0917-0009	Education Verification
Indian Health Service (IHS) Conditions of Application and Release	0917-0009	Conditions of Application and Release
Indian Health Service Statement of Health	0917-0009	Statement of Health
Initial Application	0917-0009	Initial App
Initial Application to Medical Staff with Signature Documents	0917-0009	IHS Medical Staff - Initial Application
Malpractice Verification	0917-0009	Malpractice Verification
Peer Reference Verification	0917-0009	Peer Reference Form
Pre-Application MD APP	0917-0009	Pre-Application MD App
Reappointment Application	0917-0009	Reappointment App
Reappointment Application	0917-0009	IHS MEDICAL STAFF - REAPPOINTMENT APPLICATION

---

ICR Summary of Burden

table that charts list of burden

	Total Request	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	24,787	2,700	0	24,787	-2,700	0
Annual Time Burden (Hours)	6,747	1,400	0	6,747	-1,400	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: The program changes were necessary. The program is using additional verification methods, and incorporating forms that are necessary for medical verification, and mitigation of issues related to credentialing of medical providers.

---

Annual Cost to Federal Government: $2,803,420

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? No

---

Common Form ICR:  No

---

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: 08/01/2023

---