OMB control number

Indian Health Service Medical Staff Credentials Application

OMB 0917-0009 · HHS/IHS.

OMB 0917-0009

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.

The latest form for Indian Health Service Medical Staff Credentials Application expires 2027-07-31 and is listed under ICR 202307-0917-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 0917-0009 Peer Reference Verification	Form and Instruction
Form 0917-0009 Malpractice Verification	Form and Instruction
Form 0917-0009 Education Verification	Form and Instruction
Form 0917-0009 Affiliation Verification	Form and Instruction
Form 0917-0009 Credentialing by Proxy Intake Form	Form and Instruction
Form 0917-0009 Reappointment Application	Form and Instruction
Form 0917-0009 Indian Health Service Statement of Health	Form and Instruction
Form 0917-0009 Initial Application	Form and Instruction
Form 0917-0009 Indian Health Service (IHS) Conditions of Application and Release	Form and Instruction
Form 0917-0009 Pre-Application MD APP	Form and Instruction
Form 0917-0009 Reappointment Application	Form and Instruction
Form 0917-0009 Initial Application to Medical Staff with Signature Documents	Form and Instruction
OMB 0917-0009 Supporting Statement - FINAL 7.31.23.docx	Supporting Statement A
Peer Reference Verification	Form and Instruction
Malpractice Verification	Form and Instruction
Education Verification	Form and Instruction
Affiliation Verification	Form and Instruction
Credentialing by Proxy Intake Form	Form and Instruction
Reappointment Application	Form and Instruction
Indian Health Service Statement of Health	Form and Instruction
Initial Application	Form and Instruction
Indian Health Service (IHS) Conditions of Application and Release	Form and Instruction
Pre-Application MD APP	Form and Instruction
Reappointment Application	Form and Instruction
Initial Application to Medical Staff with Signature Documents	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202307-0917-001	Revision of a currently approved collection	2023-08-01	Approved with change
202002-0917-002	Revision of a currently approved collection	2020-02-27	Approved with change
201607-0917-001	Revision of a currently approved collection	2016-08-11	Approved with change
201306-0917-001	Revision of a currently approved collection	2013-06-18	Approved without change
201004-0917-003	Extension without change of a currently approved collection	2010-04-30	Approved without change
200611-0917-002	Extension without change of a currently approved collection	2006-11-30	Approved without change
200306-0917-001	Reinstatement without change of a previously approved collection	2003-06-16	Approved without change
200211-0917-002	Extension without change of a currently approved collection	2002-11-27	Approved without change
199906-0917-001	Reinstatement with change of a previously approved collection	1999-06-09	Approved without change
199507-0917-001	Reinstatement with change of a previously approved collection	1995-07-20	Approved without change
199108-0917-001	Extension without change of a currently approved collection	1991-08-16	Approved without change
198904-0917-004	No material or nonsubstantive change to a currently approved collection	1989-04-18	Approved with change
198904-0917-001	No material or nonsubstantive change to a currently approved collection	1989-04-04	Approved with change
198806-0917-001	New collection (Request for a new OMB Control Number)	1988-06-15	Approved without change

OMB Details

Initial Application to Medical Staff with Signature Documents

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form 0917-0009	IHS Medical Staff - Initial Application	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.