HEALTH INSURANCE CLAIM FORM

ICR 198609-0704-011

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
165213 Migrated
ICR Details
0704-0110 198609-0704-011
Historical Active 198605-0704-004
DOD/DODDEP
HEALTH INSURANCE CLAIM FORM
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/17/1986
Approved with change 09/17/1986
Retrieve Notice of Action (NOA) 09/17/1986
  Inventory as of this Action Requested Previously Approved
07/31/1987 07/31/1987 07/31/1987
1,239,100 0 722,004
619,550 0 361,002
0 0 0

THE HEALTH INSURANCE CLAIM FORM IS USED TO OBATIN INFORMATION RALATIVE TO MEDICAL CLAIMS, IDENTIFY BENEFICIARIES AND DETERMINE ELIGIBILITY. IT IS ALSO USED TO DECIDE IF THE MEDICAL SERVICES AND SUPPLIES RECEVIE ARE COVERED BY CHAMPUS 5

None
None


No

1
IC Title Form No. Form Name
HEALTH INSURANCE 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 1,239,100 722,004 0 0 517,096 0
Annual Time Burden (Hours) 619,550 361,002 0 0 258,548 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.
09/17/1986


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