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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

     Indian Health Manual
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Part 2, Chapter 4:  Manual Appendix G

IHS/Tribal Section 813(b)(1)(A)
Joint Determination Worksheet

  1. Types of direct care health services to be requested for provision under section 813 (See Section E(1)a.):  Please check all boxes that apply.

    • Medical care

    • Dental care

    • Pharmacy _____ 340B ___ FSS

    • Mental health

    • Other __________________________

  2. Alternative health facilities or services available (See Section E(1)b):

    1. _________________________________________________

    2. _________________________________________________

    3. _________________________________________________

  3. Population (See Section E(1)c):

  4. Estimated population of ineligible individuals residing within the Service area:_____________________.
    Estimated population of ineligible individuals expected to utilize the IHS operated health facility:_____________.

  5. Additional extenuating factors to consider (See Section E(3) and Section F(1) and (2):

    • Distance from alternate services____________________

    • Episodic inclement weather ____________________

    • Other relevant factors ____________________

    • _____________________________________________________________________________________

    All information contained on this form will be considered in making the determination required by policy (See Section E and F).

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