Credentialing by Proxy Intake Form

Indian Health Service Medical Staff Credentials Application

Documents and Forms

Document Name Document Type
Form 0917-0009 Credentialing by Proxy Intake Form Form and Instruction
0917-0009 Cred by Proxy IHS Credentialing by Proxy Intake Form 06 26 2023 FINAL.pdf Form and Instruction
0917-0009 Credentialing by Proxy Intake Form IHS Credentialing by Proxy Intake Form FINAL 07 11 2024.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Credentialing by Proxy Intake 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	0917-0009	Credentialing by Proxy Intake Form	IHS Credentialing by Proxy Intake Form FINAL 07 11 2024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	63	63
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.