Information Collection

TRICARE Dental Program (TDP) Claim Form

IC 5616 under ICR 200911-0720-003 · OMB 0720-0035.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form TRICARE Dental Program (TDP) Claim Form	Form
Form TRICARE Dental Program Claim Form (CONUS) TDP Claim Form (CONUS).pdf	Form
Form TRICARE Dental Program Claim Form (OCONUS) TDP Claim Form (OCONUS).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	Form	TRICARE Dental Program Claim Form (CONUS)	TDP Claim Form (CONUS).pdf		Yes	Yes	Fillable Fileable
Form	Form	TRICARE Dental Program Claim Form (OCONUS)	TDP Claim Form (OCONUS).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: 64,930

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 35 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4,025,660	521,916	3,503,744
Annual IC Time Burden (Hours)	1,006,415	130,479	875,936
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.