Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0020 can be found here:

Documents and Forms

Document Name Document Type
Application for TRICARE Provider Status.pdf Other-Application

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for CHAMPUS-Provider Status: CORPORATE SERVICES PROVIDER	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 199.6

Information Collection Instruments:

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

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	4,400	4,400

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.