TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

OMB: 0720-0006

IC ID: 43597

Information Collection (IC) Details

View Information Collection (IC)

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment dd2642.pdf Yes No Fillable Printable

Defense and National Security Operational Defense

 

3,000,000 0
   
Individuals or Households
 
   15 %

  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 3,000,000 0 0 600,000 2,400,000 0
Annual IC Time Burden (Hours) 750,000 0 0 150,000 600,000 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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