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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0006 can be found here:

Documents and Forms

Document Name Document Type
Form DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form
DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for dd2642.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,000,000	600,000	2,400,000
Annual IC Time Burden (Hours)	750,000	150,000	600,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.