MEDICAL RECORDS REQUEST

ICR 197809-0704-002

OMB: 0704-0095

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
108645 Migrated
ICR Details
0704-0095 197809-0704-002
Historical Active
DOD/DODDEP
MEDICAL RECORDS REQUEST
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 09/29/1978
Retrieve Notice of Action (NOA) 09/27/1978
  Inventory as of this Action Requested Previously Approved
07/31/1983 07/31/1983
2,400 0 0
2,400 0 0
0 0 0

SOLICITATION IS NECESSARY TO PROVIDE MEDICAL INFORMATION REQUIRED IN THE PREAUTHORIZATION EVALUATION PROCESS OF CHAMPUS BENEFICIARIES REQUESTING SERVICES AND TREATMENT FROM PSYCHIATRIC RESIDENTIAL TREATMENT CENTERS FOR CHILDREN AND ADOLESCENTS.

None
None


No

1
IC Title Form No. Form Name
MEDICAL RECORDS REQUEST CHAMPUS, 345

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,400 0 0 0 2,400 0
Annual Time Burden (Hours) 2,400 0 0 0 2,400 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/27/1978


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