Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

ICR 200306-0720-001

OMB: 0720-0020

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0720-0020 200306-0720-001
Historical Active 199902-0720-001
DOD/DODOASHA
Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 07/29/2003
Retrieve Notice of Action (NOA) 06/26/2003
  Inventory as of this Action Requested Previously Approved
07/31/2006 07/31/2006
1,000 0 0
333 0 0
0 0 0

The information collection requirement is necessary to ensure that applicants for CHAMPUS-Provider Status meet the conditions for authorization as a CHAMPUS Corporate Services Provider. The collected nformation will be used by CHAMPUS contractors to process claims and verify authorization status.

None
None


No

1
IC Title Form No. Form Name
Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

  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 1,000 0 0 1,000 0 0
Annual Time Burden (Hours) 333 0 0 333 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
06/26/2003


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