IHS-976 Purchased Referred Care Proof of Residency

IHS-### (10/2017) DEPARTMENT OF HEALTH AND HUMAN SERVICE FORM APPROVED: OMB NO. 0917-####

Indian Health Service Expiration Date: MM/DD/YYYY

See OMB Statement on Page 3

PURCHASED / REFERRED CARE

PROOF OF RESIDENCY

The Indian Health Service (IHS) provides services through Purchased/Referred Care (PRC) to American Indian/Alaska Native people who live within the designated geographic area known as a PRC delivery area. The PRC program is authorized to pay for medical care provided to IHS beneficiaries by non-IHS or Tribal, public or private health care providers, depending on the availability of funds.

Federal law generally requires residency within the PRC delivery area in order to receive services through PRC. If you are requesting PRC authorization of payment by the IHS for medical services/treatment from a non-IHS provider, you must prove that you reside within the PRC delivery area.

Please print when completing this form. If you need help in completing the sections, you may ask for assistance and instructions from the IHS PRC Office.

Section A: Your Information (Required)

Last Name

First Name

Middle Initial

Date of Birth

Is this your legal name?

Yes

No

If not, what is your legal name?

Home street address:

Post Office Box:

Home phone number:

City:

State:

Zip Code:

Cell phone number:

Physical location: (For Post Office Box addresses, provide house location with street or road and the nearest intersection.)

Have you lived at this location for more

If not, provide your old address.

than six months?

Yes

No

Are you homeless?

Yes

No

Contact phone number:

Verification Statement By signing this form, under perjury of law, I verify that the information provided is true and factual to the best of my knowledge. I know that if I knowingly and willfully give any false information, that a false statement on any part of this declaration or attached documents may be grounds for punishment by a fine or imprisonment. (18 U.S.C. § 1001) I know that IHS PRC will check this information and I agree to cooperate with their information requests. I understand that the IHS PRC is only available to beneficiaries of the IHS who live in the PRC delivery area.

Applicant Signature

Date

Provide one of the following to show that you live within the PRC delivery area.

Valid State driver’s license or State Issued ID card	Employment check stub received within the past thirty (30) days showing address and withholding taxes.	Utility Bill: electric, gas, water, cable, cell phone, or telephone issued within the last sixty (60) days.
Tribal ID card with a photo	Homeowner’s or renter’s insurance policy	Rental or lease agreement
U.S. Passport	Mortgage Statement	Rental payment receipt
Voter’s registration card	Property Tax Bill	Settlement Papers
Valid college ID with a photo	Property Deed	Marriage License
Other Tribal government issued documents.

If you do not have any of these documents, you can prove that you live in the PRC delivery area by completing Section B or Section C.

Another resident of the PRC delivery area, who knows where you live, can verify your residency by filling out Section B. If you do not know anyone who is willing or able to verify where you live, a local non-profit social services provider can verify your residency by completing Section C.

Section B: Individual Verifier’s Information (Retain Section B. in PRC administrative file)

This section must be filled out by a resident who knows where you, the applicant, live – someone you live with is best. If you do not know anyone who is willing or able to verify where you live, a local non-profit organization that provides you with services may complete Section C for you. (You do not need to fill in Section C if this section is completed.)

Last Name:

First Name:

Middle Initial

Home address:

Post Office Box:

Home phone number:

City:

State:

Zip Code:

Cell phone number:

Physical location: (For Post Office Box addresses, provide house location with street or road and the nearest intersection.)

How do you know the applicant?

Verification Statement By signing this form, under perjury of law, I verify that the information provided is true and factual to the best of my knowledge. I know that if I knowingly and willfully give any false information, that a false statement on any part of this declaration or attached documents may be grounds for punishment by a fine or imprisonment. (18 U.S.C. § 1001) I know that IHS PRC will check this information and I agree to cooperate with their information requests. I understand that the IHS PRC is only available to people who live in the PRC delivery area. By signing below, I verify that, to the best of my knowledge, the applicant listed in Section A on page 1 lives at the location stated in Section A.

Verifier’s Signature

Date

The individual verifier must sign Section B and provide a copy of at least one (1) of the following documents showing the verifier’s name and address.

Valid State driver’s license or State Issued ID card

Employment check stub received within the past thirty (30) days showing name and address.

Utility Bill: electric, gas, water, cable, cell phone, or telephone issued within the last sixty (60) days.

Tribal ID card with a photo

Homeowner’s or renter’s insurance policy

Rental or lease agreement

Valid U.S. Passport

Mortgage Statement

Rental payment receipt

Voter’s registration card

Property Tax Bill

Settlement Papers

Property Deed

Section C: Organizational Verifier’s Information
This section must be filled out by a local non-profit organization, social services, or other services organization that serves you, the applicant. (You do not need to fill in Section B if this section is completed.)
Organization Name:				Organization Tax Exempt ID Number:
Verifier’s Name:				Verifier’s Title:
Telephone number:			Email address:
Organization Address:
City:				State:				Zip Code:
Verification Statement By signing this form, under perjury of law, I verify that the information provided is true and factual to the best of my knowledge. I know that if I knowingly and willfully give any false information, that a false statement on any part of this declaration or attached documents may be grounds for punishment by a fine or imprisonment. (18 U.S.C. § 1001) I know that IHS PRC will check this information and I agree to cooperate with their information requests. I understand that the IHS PRC is only available to people who live in the PRC delivery area. By signing below, I verify that, to the best of my knowledge, the applicant listed in Section A on page 1 lives at the location stated in Section A.
	Verifier’s Signature						Date

Reminder to the Applicant:

Before you turn in this application, make sure it is complete. In order to be completed, you must have:

• Section A filled out with documentation; OR
  
  

• Section A filled out with no documentation AND completed Section B or Section C.
  
  

• If you use Section B, you must have a copy of the individual verifier’s proof of residency documentation.

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. § 552a (e)(3) requires that the following notice be provided to you. The information requested on the Purchase/Referred Care (PRC) Proof of Residency form is collected to determine eligibility for and administration of PRC benefits under the Snyder Act (25 U.S.C. § 13), the Transfer Act of 1954 and implementing regulations at 42 C.F.R. Part 136. Purposes and uses – the information requested is collected for the purposes of reviewing eligibility for PRC services. The information provided on this form will be maintained in the applicant’s medical record. The information will not be disclosed to entities outside the Indian Health Service (IHS) without prior written permission except for routine uses identified in the IHS System of Records 09-17-0001 Medical, Health and Billing Records. Effects of nondisclosure – the information is required in order to determine eligibility for the receipt of PRC services.

OMB Burden Statement

Public reporting burden for this collection of information is estimated to average 3 minutes per response including time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Mail Stop 09E70, Rockville MD 20857, RE: OMB No. 0917-####. Please DO NOT SEND this form to this address.