This information
collection request is approved under the following conditions: DoD
will establish a plan under which all of its claims submissions
will migrate to electronic submission and the timing of th plans
will be consistent with any government-wide initiatives to
facilitate the adoption of data standards developed in keeping with
Circular A-119. The details of the plan will be submitted to OMB
once they are developed and no later than the next submission of
this claim form for review.
Inventory as of this Action
Requested
Previously Approved
10/31/1996
10/31/1996
09/30/1994
9,550,000
0
7,800,000
2,387,500
0
1,950,000
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.
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.