Indian Health Service
Purchased/Referred Care Proof of Residency
September 27, 2017
Supporting Statement A and B
Justification
OMB Control No. 0917- XXXX
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.
This is a request for new request information collection on a 3-year renewal information collection activity, 0917-XXXX, “Indian Health Service (IHS) Purchased/Referred Care Proof of Residency.” The Snyder Act (25 U.S.C. 13), the Transfer Act (Public Law 83-568, 42 U.S.C. 2001) and the IHS Regulations at 42 CFR 136.24, Subpart C, authorize the IHS to contract for health care services for American Indian and Alaska Native (AI/AN) people eligible to receive such care (Attachment 1).
The form, “Purchased/Referred Care Proof of Residency” will serve as an alternative means to document purchased/referred care patient’s residency to comply with eligibility regulations of eligible individual residing within the IHS Purchase/Referred Care delivery area (PRCDA).
Individuals who may be potentially eligible for IHS purchased/referred care services complete the majority of the information contained on this form. The individuals and/or designated alternate complete and sign the streamlined form and submit it, along with the requested documents to IHS for verification and eligibility determination.
The information collected is needed to administer and manage the purchased/referred care program to provide services to eligible AI/AN patients. The form is used 1) to determine purchased/referred care eligible patients, 2) to certify that the requested and 3) to ensure submitted documents have been researched and verified to process eligibility of residence. The documents provided will serve as a legal documentation for an individual’s residency within an IHS PRCDA.
The information collected is for planning for further care of the patient, for keeping an accurate record of the patient’s residency status, for planning future health care programs, for communicating among members of the health care team, for evaluating the health care and continuing education and for the provision of program health statistics.
As appropriate, IHS referral care information system, automated information technology will be used to collect and process this data; however, currently the most appropriate methodology for obtaining the information is written responses on an information collection form. An electronic fill-in form is being developed as part of automated information technology as an option for the individual to download and fill-in. Only the methodology processing the fill-in and written responses for information collection on form will be the standard. The electronic generating of data in the IHS system is standard.
Duplication is not a problem. The required residency data is not shared information located on other systems of other agencies. This is the initial process for an individual to establish residency documentation for the IHS purchase/referred care system. Only the IHS can initiate the proof of residency form, this is only one form is completed by each individual submitting residency documentation
The collection of this information does not directly impact small businesses or small entities.
Proof of residency is mandatory requirement for residency under federal regulations for PRC eligibility. If this information collection was not documented, the functions described in item 2 above would be curtailed. If not collected less frequently, the IHS would not be in compliance on eligibility compliance for residency processing to validate a residency. There are no technical or legal obstacles to reducing burden.
There are no special circumstance relating to these guidelines. This request fully complies with the regulation.
A.8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency
A 60-day notice Federal Register Notice was published in the Federal Register on
March 30, 2018, 83 FR 13764. There was one comment received and addressed in the 30 day notice published September 25, 2018 (83 FR 48450) with no comments received to OMB.
A.9. Explanation of Any Payment or Gift to Respondents
No payment or gift to respondents has been or will be made.
The information collected is maintained as part of Privacy Act System of Records,
09-17-0001, Medical, Health and Billing Records Systems, HHS/IHS/ OHP, published in Privacy Act Issuances, 2006 Compilation, online via GPO Access.
A Privacy Act Notification Statement is contained in the subject form.
A.11. Justification of Sensitive Questions
This collection does not address any matters of a sensitive nature.
Table A-3. Estimated Annualized Burden Hours
Type of Respondent |
Form Name |
No. of Respondents |
No. Responses per Respondent |
Average Burden per Response (hours)* |
Total Burden (hours) |
Individual |
User Count |
77,185 |
1 |
3/60 |
3,859.25 |
|
|
|
|
|
|
Total |
- |
77,185 |
1 |
3/60 |
3,859.25 |
*For ease of understanding, the average burden per response is 3 minutes.
Table A-4 lists the estimated annualized burden costs.
Table A-4. Estimated Annualized Burden Costs
Type of Respondent
|
Total Burden Hours
|
Hourly Wage Rate
|
Total Respondent Costs
|
Individual |
3,859.25 |
0 |
0 |
|
|
|
|
Total |
3,859.25 |
0 |
0 |
There is no anticipated cost burden to the respondents resulting from the collection of information, except the costs associated with their time. There are no capital/startup costs associated with this collection of information.
There will be no annual cost to the Federal government.
There are no program changes or adjustments. This is a new collection.
A.16. Plan for Tabulation, Publication, and Project Time Schedule
There are no plans to publish data from this information collection.
Display of the OMB expiration date is appropriate and will be placed on all forms.
A.18. Exceptions to Certification for Paperwork Reduction Act Submissions
There are no exceptions to the certification.
This section is not mandatory
B.3. Methods to Maximize Response Rates and Deal with Nonresponse
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | National Survey of Lead Hazards in Housing |
| Author | Lillian L. Deitzer |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |