OMB control number
Indian Health Service Purchased/Referred Care Proof of Residency
OMB 0917-0040 ยท HHS/IHS.
OMB 0917-0040
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.
The latest form for Indian Health Service Purchased/Referred Care Proof of Residency expires 2022-03-31 and is listed under ICR 201811-0917-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form IHS-976 IHS Proof of Residency Form | Form and Instruction |
| OMB ICR Supporting Statement A and B - PRC FINAL 4.5.22.docx | Supporting Statement A |
 IHS Proof of Residency Form |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202201-0917-003 | Reinstatement without change of a previously approved collection | 2022-04-25 | Approved without change | |
| 201811-0917-001 | New collection (Request for a new OMB Control Number) | 2018-11-23 | Approved with change |