CHAMPUS/CHAMPVA CLAIM FORM

ICR 198107-0704-013

OMB: 0704-0110

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
165211 Migrated
ICR Details
0704-0110 198107-0704-013
Historical Active 198006-0704-001
DOD/DODDEP
CHAMPUS/CHAMPVA CLAIM FORM
No material or nonsubstantive change to a currently approved collection   No
Emergency 07/17/1981
Approved with change 07/17/1981
Retrieve Notice of Action (NOA) 07/17/1981
  Inventory as of this Action Requested Previously Approved
07/31/1984 07/31/1984 06/30/1985
1,762,354 0 1,762,354
439,643 0 439,643
0 0 0

COLLECTION NECESSARY TO EVALUATE ELIGIBILITY FOR CIVILIAN HEALTH BENEFITS AUTHORIZED BY 10 USC, CHAPTER 55, AND TO ISSUE PAYMENT UPON ESTABLISHMENT OF ELIGIBILITY AND DETERMINATION THAT MEDICAL CARE RECEIVED IS AUTHORIZED BY LAW. USED TO CONTROL AND PROCESS MEDICAL CLAIMS.

None
None


No

1
IC Title Form No. Form Name
CHAMPUS/CHAMPVA CLAIM FORM CHAMPUS 501

  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 1,762,354 1,762,354 0 0 0 0
Annual Time Burden (Hours) 439,643 439,643 0 0 0 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.
07/17/1981


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