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Ihs-976 FORM IHS-976

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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
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
than six months?
Yes
No
If not, provide your old address.
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.
IHS-976 (10/2017)
Page 1 of 3
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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
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
Page 2 of 3
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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. 0917-0040. Please DO NOT SEND this form to this address.
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Completed 28 February 2020

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