Information Collection

Third Party Collection Program (Record of Other Health Insurance)

IC 5377 under ICR 200005-0704-008 · OMB 0704-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0323 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Third Party Collection Program (Record of Other Health Insurance)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD-2569				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 293,401	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	293,401	219,177	74,224
Annual IC Time Burden (Hours)	12,030	8,987	3,043
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.