Information Collection

Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

IC 5593 under ICR 201604-0720-001 · OMB 0720-0020.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form X644 Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER	Form
DD Form X644 Corporate Services Provider Application for TRICARE Prov ddx644_20160112.PDF	Form

IC Title:

Application for TRICARE-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:

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	DD Form X644	Corporate Services Provider Application for TRICARE Provider Status	ddx644_20160112.PDF		No		Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300	-700	1,000
Annual IC Time Burden (Hours)	100	-233	333
Annual IC Cost Burden (Dollars)	1,710	1,710	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.