CHAMPUS/CHAMPVA FORM 500

ICR 198609-0704-008

OMB: 0704-0084

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
165186 Migrated
ICR Details
0704-0084 198609-0704-008
Historical Active 198605-0704-003
DOD/DODDEP
CHAMPUS/CHAMPVA FORM 500
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/09/1986
Approved with change 09/09/1986
Retrieve Notice of Action (NOA) 09/09/1986
  Inventory as of this Action Requested Previously Approved
01/31/1988 01/31/1988 01/31/1988
4,040,000 0 3,700,905
2,262,000 0 2,072,507
0 0 0

THE CHAMPUS FORM 500 IS USED BY CHAMPUS BENEFICIARIES AND HEALTH CARE PROVIDERS TO FILE FOR REIMBURSEMENT OF HEALTH CARE SERVICES. THE REQUESTED INFORMATION IS USED TO DETERMINE ELIGIBILITY, APPROPRIATENES AND COST OF CARE, AND WHETHER SERVICES RECEIVED ARE BENEFITS.

None
None


No

1
IC Title Form No. Form Name
CHAMPUS/CHAMPVA FORM 500 CHAMPUS/, CHAMPVA 500

  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 4,040,000 3,700,905 0 0 339,095 0
Annual Time Burden (Hours) 2,262,000 2,072,507 0 0 189,493 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.
09/09/1986


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