Health Insurance Claim Form

HEALTH INSURANCE CLAIM FORM

OMB: 0704-0110

IC ID: 165213

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Information Collection (IC) Details

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HEALTH INSURANCE CLAIM FORM
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CHAMPUS 501 No No


    

510,438 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,239,100 0 0 517,096 0 722,004
Annual IC Time Burden (Hours) 619,550 0 0 258,548 0 361,002
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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