IHS Contract Health Service Report

Forms and Documents

Document Name	Status
Form IHS-843-1A Order for Health Services Form and Instruction	Removed
Form OMB No. 0917-0002, IHS-843-1A, Order for Health Services Form and Instruction	New
IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records.pdf Supplementary Document	2013-01-18
42 C.F.R. 136.24.pdf Supplementary Document	2012-11-09
TRANSFER_ACT_PubLaw_83_568_1954[1].pdf Supplementary Document	2012-11-09
SnyderAct[1].pdf Supplementary Document	2012-11-09
OMB No 0917-0002 SUPPORTING STATEMENT A 1-15-2013[1].doc Supporting Statement A	2013-02-08

IC Document Collections

IC ID	Document Title	Status
6559	Order for Health Services Form and Instruction	Removed
46026	Inpatient Discharge Summary	Removed
205728	IHS-843-1A, Order for Health Services Form and Instruction	New

ICR Details

OMB Control No: 0917-0002	ICR Reference No: 201302-0917-001
Status: Historical Active	Previous ICR Reference No: 201001-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No: 17884
Title: IHS Contract Health Service Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/10/2013
	Date Received in OIRA: 02/08/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved	04/30/2013
Responses	414,804	0	393,781
Time Burden (Hours)	20,740	0	19,689
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected is needed to administer and manage the contract health care services provided to eligible AI/AN patients. The form is used to: authorize contract health care services for eligible patients; certify that the health care services requested and authorized have been performed by the contract provider(s); process payments for health care services performed by such providers; obtain program data; and, serve as a legal document for health and medical care authorized by the IHS and rendered by health care providers under contract with the IHS. The information collected is also used for planning for further care of the patient, for keeping an accurate record of the patient's health status and health services received and recommended, for planning future health care programs, for communicating among members of the health care team, for evaluating the health care rendered, for research and continuing education and for the provision of program health statistics.

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Authorizing Statute(s): PL: Pub.L. 83 - 568 1-6 Name of Law: The Transfer 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:
	77 FR 69865	11/12/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 7436	02/01/2013
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
IHS-843-1A, Order for Health Services	OMB No. 0917-0002, IHS 843-1A	OMB No. 0917-0002, IHS 843-1A, Order for Health Service
Order for Health Services	IHS-843-1A	Order for Health Services
Inpatient Discharge Summary

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ICR Summary 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	414,804	393,781	0	0	21,023	0
Annual Time Burden (Hours)	20,740	19,689	0	0	1,051	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The annual burden hours for this information collection increased 1809 hours from the previously approved 18,931 hours to the current 20,740 hours. This increase in burden hours is due to an Adjustment in OPDIV Estimates, and reflects an increase in numbers of AI/ANs returning to the community; Tribal compacting/contracting of IHS programs usage; number of patient visits; claims submitted; and providers utilized. Additionally, while there were minor text changes (i.e., updating of statute/regulatory citations), there were no significant changes to the form. Also, the previously approved collection listed a "Inpatient Discharge Summary" form on the Estimates of Hour Burden Including Annualized Hourly Cost table. However, it is not included on this collection because the program stated it is a non-federal government document that non-Federal providers submit to any third party when seeking reimbursement for medical services provided to a patient.

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Annual Cost to Federal Government: $1,039,222

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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: 02/08/2013

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