PRESCRIPTION BILLING OUTPATIENT PHARMACEUTICAL SERVICES (CHAMPUS)

ICR 198305-0704-002

OMB: 0704-0089

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0704-0089 198305-0704-002
Historical Active 197806-0704-006
DOD/DODDEP
PRESCRIPTION BILLING OUTPATIENT PHARMACEUTICAL SERVICES (CHAMPUS)
Revision of a currently approved collection   No
Regular
Approved without change 06/22/1983
Retrieve Notice of Action (NOA) 05/04/1983
  Inventory as of this Action Requested Previously Approved
06/30/1986 06/30/1986 06/30/1983
25,000 0 35,000
6,250 0 8,750
0 0 0

CHAMPUS DA FORM 1863-4 IS NECESSARY TO COLLECT INFORMATION TO EVALUAT ELIGIBILITY FOR CIVILIAN HEALTH BENEFITS AUTHORIZED AND TO ISSUE CHECK UPON ESTABLISHMENT OF ELIGIBILITY AND DETERMINATION THAT PHARMACEUTICA RECEIVED ARE OBTAINABLE ONLY BY PRESCRIPTION.

None
None


No

1
IC Title Form No. Form Name
PRESCRIPTION BILLING OUTPATIENT PHARMACEUTICAL SERVICES (CHAMPUS) DA 1863-4

  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 25,000 35,000 0 0 -10,000 0
Annual Time Burden (Hours) 6,250 8,750 0 0 -2,500 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.
05/04/1983


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