Information Collection

Application For Preauthorization Or Recertification Of Champus/champva Benefits

IC 108653 under ICR 197809-0704-005 · OMB 0704-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

APPLICATION FOR PREAUTHORIZATION OR RECERTIFICATION OF CHAMPUS/CHAMPVA BENEFITS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	CHAMPUT	No	No
Form	190	No	No
Form	CHAMPUS 190	No	No
Form	CHAMPUS 190A	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	7,000	7,000
Annual IC Time Burden (Hours)	7,000	7,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.