OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

IHS Proof of Residency Form

IC 234054 under ICR 202201-0917-003 · OMB 0917-0040.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

IHS Proof of Residency Form
 
No Unchanged
 
Mandatory
 

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

Health Health Care Services

Medical, Health, and Billing Records System  83 FR 6591

77,185 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 77,185 0 0 0 77,185 0
Annual IC Time Burden (Hours) 3,859 0 0 0 3,859 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.