HEALTH INSURANCE CLAIM FORM

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
109129	HEALTH INSURANCE CLAIM FORM Form	Migrated

ICR Details

OMB Control No: 0704-0325	ICR Reference No: 199105-0704-001
Status: Historical Active	Previous ICR Reference No: 199106-0720-001
Agency/Subagency: DOD/DODDEP	Agency Tracking No:
Title: HEALTH INSURANCE CLAIM FORM
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/13/1991
	Date Received in OIRA: 05/13/1991
Terms of Clearance: This form and its associated instructions are approved through December 1991, consistent with the approval we have granted to the HCFA 1500. Because this is a common form, it shall display the current OMB approval numbers for all three agencies. Agencies shall include the public burden disclosure statement required at 5 cfr 1320.21 at the beginning of the form's instructions, and shall include a notice on the form which refers to the existence of this statement. We note that the unit burden estimates that the agencies have made for this form vary greatly, even though the required data does not. Prior to their next submissions, DOD, HHS, and DOL should work together to develop a common burden estimate for completing those portions of the form common to all. The next submissions shall discus the computation of the common estimate and any deviations that may exist.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1991	12/31/1991
Responses	6,500,000	0	0
Time Burden (Hours)	3,250,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: THE HCFA 1500 IS A NATIONAL STANDARD CLAIM FORM APPROVED BY CHAMPUS FOR INDIVIDUAL HEALTH CARE PROVIDERS AND SUPPLIERS TO FILE FOR REIMBURSEMENT FOR SERVICES OR SUPPLIES PROVIDED TO CHAMPUS OR CHAMPVA BENEFICIARIES. THE REQUESTED INFORMATION IS USED TO DETERMINE ELIGIBILITY, APPROPRIATENESS AND COST OF CARE AND WHETHER SERVICES RECEIVED ARE BENEFITS.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
HEALTH INSURANCE CLAIM FORM	HCFA-1500

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ICR Summary of Burden

	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	6,500,000	0	0	0	6,500,000	0
Annual Time Burden (Hours)	3,250,000	0	0	0	3,250,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/13/1991

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