Information Collection

Prescription Billing Outpatient Pharmaceutical Services (champus)

IC 108634 under ICR 198305-0704-002 · OMB 0704-0089.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0089 can be found here:

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Information Collection (IC) Details

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IC Title:	PRESCRIPTION BILLING OUTPATIENT PHARMACEUTICAL SERVICES (CHAMPUS)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DA 1863-4				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	25,000	-10,000	35,000
Annual IC Time Burden (Hours)	6,250	-2,500	8,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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