Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

OMB: 0720-0020

IC ID: 5593

Documents and Forms
Information Collection (IC) Details

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Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER
 
No Modified
 
Required to Obtain or Retain Benefits
 
32 CFR 199.6

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Application Application for TRICARE Provider Status.pdf No   Paper Only

Health Health Care Services

 

200 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 200 0 -800 0 1,000 0
Annual IC Time Burden (Hours) 200 0 -133 0 333 0
Annual IC Cost Burden (Dollars) 4,400 0 4,400 0 0 0

Title Document Date Uploaded
0720-0020 Signed 83-I.pdf 0720-0020 Signed 83-I.pdf 09/29/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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