Information Collection

Health Insurance Claim Form

IC 5564 under ICR 200709-0720-003 · OMB 0720-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS 1500 Health Insurance Claim Form	Form
CMS 1500 Health Insurance Claim Form CMS1500805.pdf	Form

IC Title:

Health Insurance Claim Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.7

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS 1500	Health Insurance Claim Form	CMS1500805.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,000,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,000,000	1,600,000	22,400,000
Annual IC Time Burden (Hours)	6,000,000	400,000	5,600,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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