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U.S. Department of Health and Human Services
Indian Health Manual

Part 2, Chapter 4: Manual Appendix G

Idian Health Service/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):

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

  4. 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).