Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
32cfr199.6.pdf	Supplementary Document	Uploaded 2006-09-29	Available
1999 Final Rule.pdf	Supplementary Document	Uploaded 2006-09-29	Available
0720-0020 SS PART A.pdf	Supporting Statement A	Uploaded 2006-09-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5593	Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER	Other-Application	Modified

ICR Details

OMB Control No: 0720-0020	ICR Reference No: 200609-0720-001
Status: Historical Active	Previous ICR Reference No: 200306-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/02/2006
	Date Received in OIRA: 09/29/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2009	36 Months From Approved
Responses	200	0	0
Time Burden (Hours)	200	0	0
Cost Burden (Dollars)	4,400	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 10 USC Chapter 55 Name of Law: null
   US Code: 5 USC 301 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 41428	07/21/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 41428	07/21/2006
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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	200	0	0	-800	0	1,000
Annual Time Burden (Hours)	200	0	0	-133	0	333
Annual Cost Burden (Dollars)	4,400	0	0	4,400	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden reduced due to a decrease in the number of respondents.

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Annual Cost to Federal Government: $11,070

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: 09/29/2006

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