Indian Health Service
Purchased/Referred Care Proof of Residency
Supporting Statement A and B
Justification
OMB Control No. 0917- 0040
The IHS Purchased/Referred Care Program needs the information requested on the PRC Proof of Residency form to verify that individuals seeking medical services through a PRC program meet the residency requirements specific to PRC under 42 C.F.R. § 136.23.
This is a request for information collection on a 3-year renewal information collection activity, 0917-0040, “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 Part 136, 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.
The form, “Purchased/Referred Care Proof of Residency” will serve as an alternative means to document Purchased/Referred Care (PRC) patient’s residency within an IHS Purchased/Referred Care delivery area (PRCDA), in accordance with the Purchased/Referred Care eligibility regulations at 42 CFR 136.23.
Individuals who may be potentially eligible for IHS PRC 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 PRC program to provide services to eligible AI/AN patients. The form is used 1) to request information regarding residency of individuals seeking medical services through PRC, 2) to verify that the individual meets the residency requirements specific to PRC under 42 C.F.R. § 136.23 using the information provided in response, and 3) to ensure submitted documents have been researched and verified to process eligibility of residence. The documents provided will serve as legal documentation of 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; and for the provision of program health statistics.
As appropriate, the IHS referral care information system and other 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 form has been developed as an option for the individual to download and fill-in. The method from processing responses will be captured on the form.
Duplication is not a problem. The required residency data is not available to IHS from any systems of other agencies. This information collection is part of the initial process for an individual to establish residency documentation for the IHS PRC Program. Only the IHS can initiate the proof of residency form, and this is the only form completed by each individual for the purposes of documenting residency.
The collection of this information does not directly impact small businesses or small entities.
Residency within a PRCDA is a requirement for eligibility under the federal regulations governing PRC. If this information was not documented, or was collected less frequently, the functions described in item 2 above would be curtailed.
There are no special circumstances 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
January 24, 2022, 87 FR 3562. There were no comments received. The 30-day notice is a reinstatement notice sending any comments received to OMB (87 FR 21181) published on April 22, 2022.
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 this 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 previously approved 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 | 2022-05-17 |