# Re-Designation of the Delivery Area for the Tolowa Dee-ni' Nation, Formerly Known as Smith River Rancheria
**AGENCY:**
Indian Health Service, HHS.
**ACTION:**
Final notice.
**SUMMARY:**
The Secretary of the Department of Health and Human Services hereby issues this final notice to re-designate the Purchased/Referred Care Delivery Area (PRCDA) for the Tolowa Dee-ni' Nation (Tribe) (previously known as the Smith River Rancheria of Smith River, California), to provide Purchased/Referred Care (PRC) services to their Tribal members residing in Curry County, Oregon, which is in the Portland Area Indian Health Service (IHS). The Tolowa Dee-ni's Tribal Headquarters is located 3 miles south of the California-Oregon border in Northern California.
The entire State of California, excluding the counties of Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura, was designated by the IHS as a PRCDA, formerly known as a Contract Health Service Delivery Area, in accordance with statute. The current PRCDA for Tolowa Dee-ni' Tribal members is the statutorily specified California PRCDA. The expanded PRCDA for the Tolowa Dee-ni' Tribe includes the statutorily specified California PRCDA and Curry County in the State of Oregon.
**DATES:**
This notice shall take effect on October 10, 2017.
**FOR FURTHER INFORMATION CONTACT:**
Terri Schmidt, Acting Director, Office of Resource Access and Partnerships, Indian Health Service, 5600 Fishers Lane, Mail stop: 10E85C, Rockville, Maryland 20857. Telephone 301/443-2694 (This is not a toll free number).
**SUPPLEMENTARY INFORMATION:**
*Background:* The IHS currently provides services under regulations codified at 42 CFR part 136, subparts A through C. Subpart C defines a Purchased/Referred Care Delivery Area (PRCDA) as the geographic area within which Purchased/Referred Care will be made available by the Indian Health Service (IHS) to members of an identified Indian community who reside in the Area. PRCDAs were previously known as Contract Health Service Delivery Areas (CHSDAs) and more recently, the IHS referred to them as Purchased/Referred Care Service Delivery Areas (PRCSDAs) or PRCDAs, but the IHS intends to consistently refer to them as PRCDAs going forward. Residence in a PRCDA by a person who is within the scope of the Indian health program, as set forth in 42 CFR 136.12, creates no legal entitlement to PRC, only potential eligibility for services. Services needed, but not available at an IHS/Tribal facility, are provided under the PRC program depending on the availability of funds, the person's relative medical priority, and the actual availability and accessibility of alternate resources in accordance with the regulations.
As applicable to the Tribes, these regulations provide that, unless otherwise designated, a PRCDA shall consist of a county that includes all or part of a reservation and any county or counties that have a common boundary with the reservation, 42 CFR 136.22(a)(6). The regulations also provide that after consultation with the Tribal governing body or bodies on those reservations included within the PRCDA, the Secretary may from time to time, re-designate areas within the United States for inclusion in or exclusion from a PRCDA. The regulations require that certain criteria must be considered before any re-designation is made. The criteria are as follows:
(1) The number of Indians residing in the area proposed to be so included or excluded;
(2) Whether the Tribal governing body has determined that Indians residing in the area near the reservation are socially and economically affiliated with the Tribe;
(3) The geographic proximity to the reservation of the area whose inclusion or exclusion is being considered; and
(4) The level of funding which would be available for the provision of PRC, 42 CFR 136.22(b).
Additionally, the regulations require that any re-designation of a PRCDA must be made in accordance with the Administrative Procedures Act (5 U.S.C. 553). See 42 CFR 136.22(c). In compliance with this requirement, we are publishing this final notice. Congress directed the IHS to designate the entire State of California as a PRCDA, excluding certain counties, under section 810 of the Indian Healthcare Improvement Act, Public Law 94-437, as amended (25 U.S.C. 1680). The IHS has utilized the congressionally specified PRCDA for the purposes of administering PRC benefits to members of the Tribe. Thus, members of the Tribe who reside outside of the statutorily established California PRCDA do not reside within the Tolowa Dee-ni's current PRCDA and are currently not eligible for PRC services.
The IHS has historically established PRCDAs in accordance with Congressional intent but has preserved regulatory flexibility to re-designate areas as appropriate for inclusion in or exclusion from PRCDA under PRC regulations. One of the criteria for such re-designations is the geographic proximity of the expanded area to the existing reservation or PRCDA. Here, the IHS is expanding the Tribe's PRCDA beyond the geographic description in 25 U.S.C. 1680 to include a county adjacent to the Tribe's existing PRCDA, in a neighboring state. There are already PRCDAs that include part of the State of California and part of another state, for example, Cocopah Tribe of Arizona, (Yuma, Arizona, and Imperial, California); Colorado River Indian Tribes of the Colorado River Indian Reservation, Arizona and California, (La Paz, Arizona; Riverside, California; San Bernardino, California; and Yuma, Arizona); Fort Mojave Indian Tribe of Arizona, California and Nevada, (Nevada; Mohave, Arizona; San Bernardino, California); and the Quechan Tribe of Fort Yuma Indian Reservation, California and Arizona, (Yuma, Arizona; and Imperial, California).
The Tolowa Dee-ni' Tribe has a significant number of Tribal members who are not residents of California. The Tribe asserts that 177 Tribal members reside outside of its PRCDA, in Curry County, in the State of Oregon, and are not able to access PRC funds from either the California Area facility (Smith River Howonquet Indian Health Center) or from the closest Portland Area facility.
Under 42 CFR 136.23, those otherwise eligible Indians who do not reside on a reservation, but reside within a PRCDA must be either members of the Tribe or maintain close economic and social ties with the Tribe. In this case, in applying the aforementioned PRCDA re-designation criteria required by operative regulations codified at 42 CFR part 136, subpart C, the following findings are made:
1. By expanding, the Tribe estimates the current eligible population will be increased by 177.
2. The Tribe has determined that these 177 individuals are members of the Tribe and they are socially and economically affiliated with the Tribe.
3. The expanded area, including Curry County in the State of Oregon, maintains a common boundary with the State of California and the statutorily created California PRCDA.
4. Generally, the Tribal members located in Curry County in the State of Oregon currently do not use the Indian health system for their PRC health care needs. The Tribe will use its existing Federal allocation for PRC funds to provide services to the expanded population. No additional financial resources will be allocated at this time by the IHS to the Tribe to provide services to Tribal members residing in Curry County in the State of Oregon.
*Public Comments:* The Agency received 32 comments, 31 of which were timely. The Agency carefully reviewed the submissions. The IHS did not consider one (1) of these comments, because it was received after the closing date. Of the 31 timely comments, 28 commenters supported the proposal to expand the Tolowa Dee-ni' PRCDA into Curry County, Oregon. These included 27 commenters from the California Area and one Congressional commenter. There were three (3) commenters representing two Tribes from the Portland Area that opposed the PRCDA expansion. The IHS will address those comments below:
*Comment:* The majority of commenters indicated support for the proposed PRCDA expansion and support for providing PRC to the Tribe's members living in Curry County, Oregon.
*Response:* The IHS appreciates the comments in support of the expansion and agrees that the expansion would allow the Tribe to authorize PRC services for its members residing in Curry County, Oregon.
*Comment:* Two commenters believed that the IHS should not be relying upon the Tribe's estimate of its members living in Curry County, Oregon, and that the IHS should either produce its own estimate or verify the Tribe's figure.
*Response:* In 2014, the IHS prepared a study of the Tolowa Dee-ni' Tribe's roster of Tribal Citizens matched with patient user activity data from the National Patient Information Reporting System. The findings of the patient matching study were consistent with a previous request conducted in 2013 by the former IHS California Area Director.
The *Federal Register* Notice states that the Smith River Tribe has estimated that 177 of its Tribal members reside in Curry County, in the State of Oregon, and they are not able to access PRC funds either at the California Area or the Portland Area. The IHS believes that this number is a fair approximation of the number of Smith River Tribal members residing in Curry County, given IHS's facility data, and recognizing that the Tribe has additional resources, such as a Tribal Membership Roll, to estimate the number of members residing in Curry County, Oregon, including those who have not yet sought services at IHS facilities and therefore would not be included in IHS data.
*Comment:* One commenter inquired about the “threshold” for expanding a PRCDA and whether there is a minimum number or percentage in terms of Tribal members.
*Response:* Each PRCDA expansion under consideration must be reviewed in accordance with the criteria set forth in 42 CFR 136.22(b), meaning this decision is a case-by-case determination based upon the facts of the particular expansion at issue. Regulations require the IHS to consider, among other factors, the “number of Indians residing in the area” of the proposed expansion, but the regulations do not require a minimum number or percentage.
*Comment:* One commenter asked why the IHS is advancing the proposal for the Tribe, after declining to accommodate requests from Oregon Tribes and whether this created a double standard.
*Response:* Previously, the IHS restricted certain PRCDA expansions based on the Agency's implementation of the regulatory “geographic proximity” requirement specified at 42 CFR 136.22(b)(3). While geographic proximity remains a necessary consideration in a PRCDA expansion, the IHS has reconsidered our previous position and recently adopted a more flexible approach. The IHS explained this change in an April 7, 2016, *Federal Register* Notice (81 FR 20388), “Notice of the Redesignation of the Service Delivery Area for the Wampanoag Tribe of Gay Head (Aquinnah).”
*Comment:* One commenter asked how the IHS verified that the Tribal members residing in Curry County, Oregon, are economically and socially affiliated with the Tribe.
*Response:* Under 42 CFR 136.22(b)(2), the IHS is required to consider whether “the Tribal governing body has determined that Indians residing in the area near the reservation are socially and economically affiliated with the Tribes.” The regulation does not require an independent investigation by the IHS on this issue. The IHS would typically defer to the Tribal governing body's determination, given the language in the regulation and a Tribe's better position to make this conclusion. However, the IHS would note that the Tribe's estimate for the expanded population includes only its members residing in Curry County, Oregon, and its members are eligible for PRC under 42 CFR 136.23, as long as the members reside within the PRCDA.
*Comment:* Two commenters inquired about the financial aspects of the expansion, such as how this proposal would be paid for and what would be the motivation, since no additional funds are being provided to the Tribe.
*Response:* Tolowa Dee-ni' Tribal members living in Curry County, Oregon, are unfunded for both IHS direct care and PRC resources. A few Tribal members have sought direct services from Tribal health programs in Oregon. While these individuals can receive direct services at the Oregon programs, no funds are allocated to the Portland Area IHS or the California Area IHS to provide services to members of the Tolowa Dee-ni' Tribe residing in Curry County. The Agency is approving the requested PRCDA expansion to allow the Tolowa Dee-ni' Tribe to authorize the purchase of PRC services, within existing funds, for members of the Tribe who reside in Curry County. Without this expansion, such purchases would not be lawful and those Tribal members would not be eligible to receive PRC services. Since there are no additional funds being provided by the IHS for the PRCDA expansion, the Tribe's current level of PRC funding will be available to serve a larger population.
*Comment:* One commenter inquired about the potential future financial impact on Oregon Tribes and how this could be accurately measured, given the current data.
*Response:* Per Agency policy, expanding a PRCDA does not automatically increase the funding to a Tribe. Tribes will continue to use existing Federal allocation for PRC funds to provide services to expanding population until Congress appropriates additional funding. Each IHS Area will distribute future increases based on their own methodologies. The Tribe may benefit from future increases to PRC funding because of the additional active users from the PRCDA expansion, but the IHS determined that there will be very little to no financial impact as a result of the expansion on Portland Area Tribes.
*Comment:* One commenter inquired about the status of a proposed pilot project for an Area-wide PRCDA in the Portland Area IHS.
*Response:* The Coquille Tribe presented a suggestion for consideration to the IHS Portland Area Funds Distribution Workgroup (FDWG). The FDWG is a Tribal consultative body that serves as a resource to the Portland Area Director on any Indian health system funds issue. The principal function of the FDWG is to develop recommendations regarding resource allocation within the Portland Area IHS. The IHS anticipates announcing a plan of action on this issue soon.
| Tribe/reservation | County/state |
| --- | --- |
| Ak Chin Indian Community | Pinal, AZ. |
| Alabama-Coushatta Tribes of Texas | Polk, TX. |
| Alaska | Entire State. |
| Arapahoe Tribe of the Wind River Reservation, Wyoming | Hot Springs, WY, Fremont, WY, Sublette, WY. |
| Aroostook Band of Micmacs | Aroostook, ME. |
| Assiniboine and Sioux Tribes of the Fort Peck Indian Reservation, Montana | Daniels, MT, McCone, MT, Richland, MT, Roosevelt, MT, Sheridan, MT, Valley, MT. |
| Bad River Band of the Lake Superior Tribe of Chippewa Indians of the Bad River Reservation, Wisconsin | Ashland, WI, Iron, WI. |
| Bay Mills Indian Community, Michigan | Chippewa, MI. |
| Blackfeet Tribe of the Blackfeet Indian Reservation of Montana | Glacier, MT, Pondera, MT. |
| Brigham City Intermountain School Health Center, Utah. Permanently Closed on May 17, 1984 | (
) |
| Burns Paiute Tribe | Harney, OR. |
| California | Entire State, except for the counties listed in the footnote. |
| Catawba Indian Nation | All Counties in SC,
Cabarrus, NC, Cleveland, NC, Gaston, NC, Mecklenburg, NC, Rutherford, NC, Union, NC. |
| Cayuga Nation | Alleghany, NY,
Cattaraugus, NY, Chautauqua, NY, Erie, NY, Warren, PA. |
| Cheyenne River Sioux Tribe of the Cheyenne River Reservation, South Dakota | Corson, SD, Dewey, SD, Haakon, SD, Meade, SD, Perkins, SD, Potter, SD, Stanley, SD, Sully, SD, Walworth, SD, Ziebach, SD. |
| Chippewa-Cree Indians of the Rocky Boy's Reservation, Montana | Chouteau, MT, Hill, MT, Liberty, MT. |
| Chitimacha Tribe of Louisiana | St. Mary Parish, LA. |
| Cocopah Tribe of Arizona | Yuma, AZ, Imperial, CA. |
| Coeur D'Alene Tribe | Benewah, ID, Kootenai, ID, Latah, ID, Spokane, WA, Whitman, WA. |
| Colorado River Indian Tribes of the Colorado River Indian Reservation, Arizona and California | La Paz, AZ, Riverside, CA, San Bernardino, CA, Yuma, AZ. |
| Confederated Salish and Kootenai Tribes of the Flathead Reservation | Flathead, MT, Lake, MT, Missoula, MT, Sanders, MT. |
| Confederated Tribes and Bands of the Yakama Nation | Klickitat, WA, Lewis, WA, Skamania, WA,
Yakima, WA. |
| Confederated Tribes of Siletz Indians of Oregon | Benton, OR,
Clackamas, OR, Lane, OR, Lincoln, OR, Linn, OR, Marion, OR, Multnomah, OR, Polk, OR, Tillamook, OR, Washington, OR, Yamhill, OR. |
| Confederated Tribes of the Chehalis Reservation | Grays Harbor, WA, Lewis, WA, Thurston, WA. |
| Confederated Tribes of the Colville Reservation | Chelan, WA,
Douglas, WA, Ferry, WA, Grant, WA, Lincoln, WA, Okanogan, WA, Stevens, WA. |
| Confederated Tribes of the Coos, Lower Umpqua and Siuslaw Indians | Coos, OR,
Curry, OR, Douglas, OR, Lane, OR, Lincoln, OR. |
| Confederated Tribes of the Goshute Reservation, Nevada and Utah | Nevada, Juab, UT, Toole, UT. |
| Confederated Tribes of the Grand Ronde Community of Oregon | Marion, OR, Multnomah, OR, Polk, OR,
Tillamook, OR, Washington, OR, Yamhill, OR. |
| Confederated Tribes of the Umatilla Indian Reservation | Umatilla, OR, Union, OR. |
| Confederated Tribes of the Warm Springs Reservation of Oregon | Clackamas, OR, Jefferson, OR, Linn, OR, Marion, OR, Wasco, OR. |
| Coquille Indian Tribe | Coos, OR, Curry, OR, Douglas, OR, Jackson, OR, Lane, OR. |
| Coushatta Tribe of Louisiana | Allen Parish, LA, Elton, LA. |
| Cow Creek Band of Umpqua Tribe of Indians | Coos, OR,
Deshutes, OR, Douglas, OR, Jackson, OR, Josephine, OR, Klamath, OR, Lane, OR. |
| Cowlitz Indian Tribe | Clark, WA, Cowlitz, WA, King, WA, Lewis, WA, Peirce, WA, Skamania, WA, Thurston, WA, Columbia, OR,
Kittitas, WA, Wahkiakum, WA. |
| Crow Creek Sioux Tribe of the Crow Creek Reservation, South Dakota | Brule, SD, Buffalo, SD, Hand, SD, Hughes, SD, Hyde, SD, Lyman, SD, Stanley, SD. |
| Crow Tribe of Montana | Big Horn, MT, Carbon, MT, Treasure, MT,
Yellowstone, MT, Big Horn, WY, Sheridan, WY. |
| Eastern Band of Cherokee Indians | Cherokee, NC, Graham, NC, Haywood, NC, Jackson, NC, Swain, NC. |
| Eastern Shoshone Tribe of the Wind River Reservation, Wyoming | Hot Springs, WY, Fremont, WY, Sublette, WY. |
| Flandreau Santee Sioux Tribe of South Dakota | Moody, SD. |
| Forest County Potawatomi Community, Wisconsin | Forest, WI, Marinette, WI, Oconto, WI. |
| Fort Belknap Indian Community of the Fort Belknap Reservation of Montana | Blaine, MT, Phillips, MT. |
| Fort McDermitt Paiute and Shoshone Tribes of the Fort McDermitt Indian Reservation, Nevada and Oregon | Nevada, Malheur, OR. |
| Fort McDowell Yavapai Nation, Arizona | Maricopa, AZ. |
| Fort Mojave Indian Tribe of Arizona, California and Nevada | Nevada, Mohave, AZ, San Bernardino, CA. |
| Gila River Indian Community of the Gila River Indian Reservation, Arizona | Maricopa, AZ, Pinal, AZ. |
| Grand Traverse Band of Ottawa and Chippewa Indians, Michigan | Antrim, MI,
Benzie, MI, Charlevoix, MI, Grand Traverse, MI, Leelanau, MI, Manistee, MI. |
| Hannahville Indian Community, Michigan | Delta, MI, Menominee, MI. |
| Haskell Indian Health Center | Douglas, KS. |
| Havasupai Tribe of the Havasupai | Coconino, AZ. |
| Ho-Chunk Nation of Wisconsin | Adams, WI,
Clark, WI, Columbia, WI, Crawford, WI, Dane, WI, Eau Claire, WI, Houston, MN, Jackson, WI, Juneau, WI, La Crosse, WI, Marathon, WI, Monroe, WI, Sauk, WI, Shawano, WI, Vernon, WI, Wood, WI. |
| Hoh Indian Tribe | Jefferson, WA. |
| Hopi Tribe of Arizona | Apache, AZ, Coconino, AZ, Navajo, AZ. |
| Houlton Band of Maliseet Indians | Aroostook, ME. |
| Hualapai Indian Tribe of the Hualapai Indian Reservation, Arizona | Coconino, AZ, Mohave, AZ, Yavapai, AZ. |
| Iowa Tribe of Kansas and Nebraska | Brown, KS, Doniphan, KS, Richardson, NE. |
| Jamestown S'Klallam Tribe | Clallam, WA, Jefferson, WA. |
| Jena Band of Choctaw Indians | Grand Parish, LA,
LaSalle Parish, LA, Rapides, LA. |
| Jicarilla Apache Nation, New Mexico | Archuleta, CO, Rio Arriba, NM, Sandoval, NM. |
| Kaibab Band of Paiute Indians of the Kaibab Indian Reservation, Arizona | Coconino, AZ, Mohave, AZ, Kane, UT. |
| Kalispel Indian Community of the Kalispel Reservation | Pend Oreille, WA, Spokane, WA. |
| Kewa Pueblo, New Mexico | Sandoval, NM, Santa Fe, NM. |
| Keweenaw Bay Indian Community, Michigan | Baraga, MI, Houghton, MI, Ontonagon, MI. |
| Kickapoo Traditional Tribe of Texas | Maverick, TX. |
| Kickapoo Tribe of Indians of the Kickapoo Reservation in Kansas | Brown, KS, Jackson, KS. |
| Klamath Tribes | Klamath, OR. |
| Koi Nation of Northern California (formerly known as Lower Lake Rancheria, California) | Lake, CA, Sonoma, CA. |
| Kootenai Tribe of Idaho | Boundary, ID. |
| Lac Courte Oreilles Band of Superior Chippewa Indians of Wisconsin | Sawyer, WI. |
| Lac du Flambeau Band of Lake Superior Chippewa Indians of the Lac du Flambeau Reservation of Wisconsin | Iron, WI, Oneida, WI, Vilas, WI. |
| Lac Vieux Desert Band of Lake Superior Chippewa Indians of Michigan | Gogebic, MI. |
| Little River Band of Ottawa Indians, Michigan | Kent, MI,
Muskegon, MI, Newaygo, MI, Oceana, MI, Ottawa, MI, Manistee, MI, Mason, MI, Wexford, MI, Lake, MI. |
| Little Traverse Bay Bands of Odawa Indians, Michigan | Alcona, MI,
Alger, MI, Alpena, MI, Antrim, MI, Benzie, MI, Charlevoix, MI, Cheboygan, MI, Chippewa, MI, Crawford, MI, Delta, MI, Emmet, MI, Grand Traverse, MI, Iosco, MI, Kalkaska, MI, Leelanau, MI, Luce, MI, Mackinac, MI, Manistee, MI, Missaukee, MI, Montmorency, MI, Ogemaw, MI, Oscoda, MI, Otsego, MI, Presque Isle, MI, Schoolcraft, MI, Roscommon, MI, Wexford, MI. |
| Lower Brule Sioux Tribe of the Lower Brule Reservation, South Dakota | Brule, SD, Buffalo, SD, Hughes, SD, Lyman, SD, Stanley, SD. |
| Lower Elwha Tribal Community | Clallam, WA. |
| Lower Sioux Indian Community in the State of Minnesota | Redwood, MN, Renville, MN. |
| Lummi Tribe of the Lummi Reservation | Whatcom, WA. |
| Makah Indian Tribe of the Makah Indian Reservation | Clallam, WA. |
| Mashantucket Pequot Indian Tribe | New London, CT. |
| Mashpee Wampanoag Tribe | Barnstable, MA, Bristol, MA, Norfolk, MA, Plymouth, MA, Suffolk, MA. |
| Match-e-be-nash-she-wish Band of Pottawatomi Indians of Michigan | Allegan, MI,
Barry, MI, Kalamazoo, MI, Kent, MI, Ottawa, MI. |
| Menominee Indian Tribe of Wisconsin | Langlade, WI, Menominee, WI, Oconto, WI, Shawano, WI. |
| Mescalero Apache Tribe of the Mescalero Reservation, New Mexico | Chaves, NM, Lincoln, NM, Otero, NM. |
| Miccosukee Tribe of Indians | Broward, FL, Collier, FL, Miami-Dade, FL, Hendry, FL. |
| Minnesota Chippewa Tribe, Minnesota, Bois Forte Band (Nett Lake) | Itasca, MN, Koochiching, MN, St. Louis, MN. |
| Minnesota Chippewa Tribe, Minnesota, Fond du Lac Band | Carlton, MN, St. Louis, MN. |
| Minnesota Chippewa Tribe, Minnesota, Grand Portage Band | Cook, MN. |
| Minnesota Chippewa Tribe, Minnesota, Leech Lake Band | Beltrami, MN, Cass, MN, Hubbard, MN, Itasca, MN. |
| Minnesota Chippewa Tribe, Minnesota, Mille Lacs Band | Aitkin, MN, Kanebec, MN, Mille Lacs, MN, Pine, MN. |
| Minnesota Chippewa Tribe, Minnesota, White Earth Band | Becker, MN, Clearwater, MN, Mahnomen, MN, Norman, MN, Polk, MN. |
| Mississippi Band of Choctaw Indians | Attala, MS, Jasper, MS,
Jones, MS, Kemper, MS, Leake, MS, Neshoba, MS, Newton, MS, Noxubee, MS,
Scott, MS,
Winston, MS. |
| Mohegan Tribe of Indians of Connecticut | Fairfield, CT, Hartford, CT, Litchfield, CT, Middlesex, CT, New Haven, CT, New London, CT, Tolland, CT, Windham, CT. |
| Muckleshoot Indian Tribe | King, WA, Pierce, WA. |
| Narragansett Indian Tribe | Washington, RI. |
| Navajo Nation, Arizona, New Mexico, & Utah | Apache, AZ, Bernalillo, NM, Cibola, NM, Coconino, AZ, Kane, UT, McKinley, NM, Montezuma, CO, Navajo, AZ, Rio Arriba, NM, Sandoval, NM, San Juan, NM, San Juan, UT, Socorro, NM, Valencia, NM. |
| Nevada | Entire State. |
| Nez Perce Tribe | Clearwater, ID, Idaho, ID, Latah, ID, Lewis, ID, Nez Perce, ID. |
| Nisqually Indian Tribe | Pierce, WA, Thurston, WA. |
| Nooksack Indian Tribe | Whatcom, WA. |
| Northern Cheyenne Tribe of the Northern Cheyenne Indian Reservation, Montana | Big Horn, MT, Carter, MT,
Rosebud, MT. |
| Northwestern Band of Shoshone Nation | Box Elder, UT. |
| Nottawaseppi Huron Band of the Pottawatomi, Michigan | Allegan, MI,
Barry, MI, Branch, MI, Calhoun, MI, Kalamazoo, MI, Kent, MI, Ottawa, MI. |
| Oglala Sioux Tribe | Bennett, SD, Cherry, NE, Custer, SD, Dawes, NE, Fall River, SD, Jackson, SD,
Mellette, SD, Pennington, SD, Shannon, SD, Sheridan, NE, Todd, SD. |
| Ohkay Owingeh, New Mexico | Rio Arriba, NM. |
| Oklahoma | Entire State. |
| Omaha Tribe of Nebraska | Burt, NE, Cuming, NE, Monona, IA, Thurston, NE, Wayne, NE. |
| Oneida Nation | Brown, WI, Outagamie, WI. |
| Oneida Nation of New York | Chenango, NY, Cortland, NY, Herkimer, NY, Madison, NY, Oneida, NY, Onondaga, NY. |
| Onondaga Nation | Onondaga, NY. |
| Paiute Indian Tribe of Utah | Iron, UT,
Millard, UT, Sevier, UT, Washington, UT. |
| Pamunkey Indian Tribe | Caroline, Hanover, Henrico, King William, King and Queen, New Kent, Richmond (Independent City). |
| Pascua Yaqui Tribe of Arizona | Pima, AZ. |
| Passamaquoddy Tribe | Aroostook, ME,
Hancock, ME,
Washington, ME. |
| Penobscot Nation | Aroostook, ME
, Penobscot, ME. |
| Poarch Band of Creeks | Baldwin, AL,
Elmore, AL, Escambia, AL, Mobile, AL, Monroe, AL, Escambia, FL. |
| Pokagon Band of Pottawatomi Indians, Michigan and Indiana | Allegan, MI,
Berrien, MI, Cass, MI, Elkhart, IN, Kosciusko, IN, La Porte, IN, Marshall, IN, St. Joseph, IN, Starke, IN, Van Buren, MI. |
| Ponca Tribe of Nebraska | Boyd, NE,
Burt, NE, Charles Mix, SD, Douglas, NE, Hall, NE, Holt, NE, Knox, NE, Lancaster, NE, Madison, NE, Platte, NE, Pottawatomie, IA, Sarpy, NE, Stanton, NE, Wayne, NE, Woodbury, IA. |
| Port Gamble S'Klallam Tribe | Kitsap, WA. |
| Prairie Band of Pottawatomi Nation | Jackson, KS. |
| Prairie Island Indian Community in the State of Minnesota | Goodhue, MN. |
| Pueblo of Acoma, New Mexico | Cibola, NM. |
| Pueblo of Cochiti, New Mexico | Sandoval, NM, Santa Fe, NM. |
| Pueblo of Isleta, New Mexico | Bernalillo, NM, Torrance, NM, Valencia, NM. |
| Pueblo of Jemez, New Mexico | Sandoval, NM. |
| Pueblo of Laguna, New Mexico | Bernalillo, NM, Cibola, NM, Sandoval, NM, Valencia, NM. |
| Pueblo of Nambe, New Mexico | Santa Fe, NM. |
| Pueblo of Picuris, New Mexico | Taos, NM. |
| Pueblo of Pojoaque, New Mexico | Rio Arriba, NM, Santa Fe, NM. |
| Pueblo of San Felipe, New Mexico | Sandoval, NM. |
| Pueblo of San Ildefonso, New Mexico | Los Alamos, NM, Rio Arriba, NM, Sandoval, NM, Santa Fe, NM. |
| Pueblo of Sandia, New Mexico | Bernalillo, NM, Sandoval, NM. |
| Pueblo of Santa Ana, New Mexico | Sandoval, NM. |
| Pueblo of Santa Clara, New Mexico | Los Alamos, NM, Sandoval, NM, Santa Fe, NM. |
| Pueblo of Taos, New Mexico | Colfax, NM, Taos, NM. |
| Pueblo of Tesuque, New Mexico | Santa Fe, NM. |
| Pueblo of Zia, New Mexico | Sandoval, NM. |
| Puyallup Tribe of the Puyallup Reservation | King, WA, Pierce, WA, Thurston, WA. |
| Quechan Tribe of the Fort Yuma Indian Reservation, Arizona and California | Yuma, AZ, Imperial, CA. |
| Quileute Tribe of the Quileute Reservation | Clallam, WA, Jefferson, WA. |
| Quinault Indian Nation | Grays Harbor, WA, Jefferson, WA. |
| Rapid City, South Dakota | Pennington, SD. |
| Red Cliff Band of Lake Superior Chippewa Indians of Wisconsin | Bayfield, WI. |
| Red Lake Band of Chippewa Indians, Minnesota | Beltrami, MN, Clearwater, MN, Koochiching, MN, Lake of the Woods, MN, Marshall, MN, Pennington, MN, Polk, MN, Roseau, MN. |
| Rosebud Sioux Tribe of the Rosebud Indian Reservation, South Dakota | Bennett, SD, Cherry, NE, Gregory, SD, Lyman, SD, Mellette, SD, Todd, SD, Tripp, SD. |
| Sac & Fox Nation of Missouri in Kansas and Nebraska | Brown, KS, Richardson, NE. |
| Sac & Fox Tribe of the Mississippi in Iowa | Tama, IA. |
| Saginaw Chippewa Indian Tribe of Michigan | Arenac, MI,
Clare, MI, Isabella, MI, Midland, MI, Missaukee, MI. |
| Saint Regis Mohawk Tribe | Franklin, NY, St. Lawrence, NY. |
| Salt River Pima-Maricopa Indian Community of the Salt River Reservation, Arizona | Maricopa, AZ. |
| Samish Indian Nation | Clallam, WA,
Island, WA, Jefferson, WA, King, WA, Kitsap, WA, Pierce, WA, San Juan, WA, Skagit, WA, Snohomish, WA, Whatcom, WA. |
| San Carlos Apache Tribe of the San Carlos Reservation, Arizona | Apache, AZ, Cochise, AZ, Gila, AZ, Graham, AZ, Greenlee, AZ, Pinal, AZ. |
| San Juan Southern Paiute Tribe of Arizona | Coconino, AZ, San Juan, UT. |
| Santee Sioux Nation, Nebraska | Bon Homme, SD, Knox, NE. |
| Sauk-Suiattle Indian Tribe | Snohomish, WA, Skagit, WA. |
| Sault Ste. Marie Tribe of Chippewa Indians, Michigan | Alger, MI,
Chippewa, MI, Delta, MI, Luce, MI, Mackinac, MI, Marquette, MI, Schoolcraft, MI. |
| Seminole Tribe of Florida | Broward, FL, Collier, FL, Miami-Dade, FL, Glades, FL, Hendry, FL. |
| Seneca Nation of Indians | Alleghany, NY, Cattaraugus, NY, Chautauqua, NY, Erie, NY, Warren, PA. |
| Shakopee Mdewakanton Sioux Community of Minnesota | Scott, MN. |
| Shinnecock Indian Nation | Nassau, NY,
Suffolk, NY. |
| Shoalwater Bay Tribe of the Shoalwater Bay Indian Reservation | Pacific, WA. |
| Shoshone-Bannock Tribes of the Fort Hall Reservation | Bannock, ID, Bingham, ID, Caribou, ID, Lemhi, ID,
Power, ID. |
| Shoshone-Paiute Tribes of the Duck Valley Reservation, Nevada | Nevada, Owyhee, ID. |
| Sisseton-Wahpeton Oyate of the Lake Traverse Reservation, South Dakota | Codington, SD, Day, SD, Grant, SD, Marshall, SD, Richland, ND, Roberts, SD, Sargent, ND, Traverse, MN. |
| Skokomish Indian Tribe | Mason, WA. |
| Skull Valley Band of Goshute Indians of Utah | Tooele, UT. |
| Snoqualmie Indian Tribe | King, WA,
Snohomish, WA, Pierce, WA, Island, WA, Mason, WA. |
| Sokaogon Chippewa Community, Wisconsin | Forest, WI. |
| Southern Ute Indian Tribe of the Southern Ute Reservation, Colorado | Archuleta, CO, La Plata, CO, Montezuma, CO, Rio Arriba, NM, San Juan, NM. |
| Spirit Lake Tribe, North Dakota | Benson, ND, Eddy, ND, Nelson, ND, Ramsey, ND. |
| Spokane Tribe of the Spokane Reservation | Ferry, WA, Lincoln, WA, Stevens, WA. |
| Squaxin Island Tribe of the Squaxin Island Reservation | Mason, WA. |
| St. Croix Chippewa Indians of Wisconsin | Barron, WI, Burnett, WI, Pine, MN, Polk, WI, Washburn, WI. |
| Standing Rock Sioux Tribe of North & South Dakota | Adams, ND, Campbell, SD, Corson, SD, Dewey, SD, Emmons, ND, Grant, ND, Morton, ND, Perkins, SD, Sioux, ND, Walworth, SD, Ziebach, SD. |
| Stillaguamish Tribe of Indians of Washington | Snohomish, WA. |
| Stockbridge Munsee Community, Wisconsin | Menominee, WI, Shawano, WI. |
| Suquamish Indian Tribe of the Port Madison Reservation | Kitsap, WA. |
| Swinomish Indian Tribal Community | Skagit, WA. |
| Tejon Indian Tribe | Kern, CA. |
| Three Affiliated Tribes of the Fort Berthold Reservation, North Dakota | Dunn, ND, Mercer, ND, McKenzie, ND, McLean, ND, Mountrail, ND, Ward, ND. |
| Tohono O'odham Nation of Arizona | Maricopa, AZ, Pima, AZ, Pinal, AZ. |
| Tonawanda Band of Seneca | Genesee, NY, Erie, NY, Niagara, NY. |
| Tolowa Dee-ni' Nation (formerly known as Smith River Rancheria of California) | California, Curry, OR. |
| Tonto Apache Tribe of Arizona | Gila, AZ. |
| Trenton Service Unit, North Dakota and Montana | Divide, ND,
McKenzie, ND, Williams, ND, Richland, MT, Roosevelt, MT, Sheridan, MT. |
| Tulalip Tribes of Washington | Snohomish, WA. |
| Tunica-Biloxi Indian Tribe | Avoyelles, LA, Rapides, LA. |
| Turtle Mountain Band of Chippewa Indians of North Dakota | Rolette, ND. |
| Tuscarora Nation | Niagara, NY. |
| Upper Sioux Community, Minnesota | Chippewa, MN, Yellow Medicine, MN. |
| Upper Skagit Indian Tribe | Skagit, WA. |
| Ute Indian Tribe of the Uintah & Ouray Reservation, Utah | Carbon, UT, Daggett, UT, Duchesne, UT, Emery, UT, Grand, UT, Rio Blanco, CO, Summit, UT, Uintah, UT, Utah, UT, Wasatch, UT. |
| Ute Mountain Ute Tribe | Apache, AZ, La Plata, CO, Montezuma, CO, San Juan, NM, San Juan, UT. |
| Wampanoag Tribe of Gay Head (Aquinnah) | Dukes, MA,
Barnstable, MA, Bristol, MA, Norfolk, MA, Plymouth, MA, Suffolk, MA. |
| Washoe Tribe of Nevada & California | Nevada, California except for the counties listed in footnote. |
| White Mountain Apache Tribe of the Fort Apache Reservation, Arizona | Apache, AZ, Coconino, AZ, Gila, AZ, Graham, AZ, Greenlee, AZ, Navajo, AZ. |
| Wilton Rancheria, California | Sacramento, CA. |
| Winnebago Tribe of Nebraska | Dakota, NE, Dixon, NE, Monona, IA, Thurston, NE, Wayne, NE, Woodbury, IA. |
| Yankton Sioux Tribe of South Dakota | Bon Homme, SD, Boyd, NE, Charles Mix, SD, Douglas, SD, Gregory, SD, Hutchinson, SD, Knox, NE. |
| Yavapai-Apache Nation of the Camp Verde Indian Reservation, Arizona | Yavapai, AZ. |
| Yavapai-Prescott Indian Tribe | Yavapai, AZ. |
| Ysleta Del Sur Pueblo of Texas | El Paso, TX. |
| Zuni Tribe of the Zuni Reservation, New Mexico | Apache, AZ, Cibola, NM, McKinley, NM, Valencia, NM. |
Dated: October 2, 2017.
Michael D. Weahkee,
RADM, Assistant Surgeon General, U.S. Public Health Service, Acting Director, Indian Health Service.