DEPARTMENT OF HEALTH AND HUMAN SERVICE
Indian Health Service
FORM APPROVED: OMB NO. 0917-0040
Expiration Date: 03/31/2022
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
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
than six months?
If not, provide your old address.
Are you homeless? Yes
No Contact phone number:
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.
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.
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