IHS Proof of Residency Form

Indian Health Service Purchased/Referred Care Proof of Residency

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0040 can be found here:

Documents and Forms

Document Name Document Type
Form IHS-976 IHS Proof of Residency Form Form and Instruction
IHS-976 Purchased Referred Care Proof of Residency Final PRC Proof of Residency - 03-21-2019 clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	IHS Proof of Residency Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	IHS-976	Purchased Referred Care Proof of Residency	Final PRC Proof of Residency - 03-21-2019 clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medical, Health, and Billing Records System	FR Citation: 83 FR 6591

Number of Respondents: 77,185	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	77,185	77,185
Annual IC Time Burden (Hours)	3,859	3,859
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.