HEALTH INSURANCE CLAIM FORM

ICR 199106-0720-001

OMB: 0720-0001

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
109238 Migrated
ICR Details
0720-0001 199106-0720-001
Historical Active
DOD/DODOASHA
HEALTH INSURANCE CLAIM FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/14/1991
Retrieve Notice of Action (NOA) 06/14/1991
  Inventory as of this Action Requested Previously Approved
12/31/1991 12/31/1991
6,500,000 0 0
3,250,000 0 0
0 0 0

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.

None
None


No

1
IC Title Form No. Form Name
HEALTH INSURANCE CLAIM FORM HCFA-1500

  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
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.
06/14/1991


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