Active Duty Dental Program Claim Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form 5579 Active Duty Dental Program Claim Form	Form	Modified	Available
United Concordia Companies IncActive Duty Dental Program PIAFinalSections 1 24292014.PDF	Supplementary Document	Uploaded 2016-04-20	Available
PAS screenshot - 0720-0053 - ADDP.docx	Supplementary Document	Uploaded 2016-04-20	Available
150917_SSN Justification 0720-0053.PDF	Supplementary Document	Uploaded 2016-04-20	Available
0720-0053 Supporting Statement Part A FINAL.doc	Supporting Statement A	Uploaded 2016-11-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203005	Active Duty Dental Program Claim Form	Form	Modified

ICR Details

OMB Control No: 0720-0053	ICR Reference No: 201604-0720-003
Status: Historical Active	Previous ICR Reference No: 201207-0720-006
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Active Duty Dental Program Claim Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/02/2016
	Date Received in OIRA: 04/21/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved
Responses	300,000	0	0
Time Burden (Hours)	75,000	0	0
Cost Burden (Dollars)	1,308,000	0	0

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Abstract: The information collection is necessary to obtain and record the dental readiness of Service Members using the Active Duty Dental Program (ADDP) and at the same time submit the claim form for the dental procedures provided. Many of these Service Members are not located near a military dental clinic and receive their dental care in the private sector under ADDP. The form is needed to update the dental readiness of all Service Members so that they can maintain worldwide deployment status and reduces paperwork by combining the dental claim and dental readiness into one form.

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Authorizing Statute(s): US Code: 10 USC 1074 Name of Law: Medical and Dental Care for Members and Certain Former Members
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 26008	05/06/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 23278	04/20/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Active Duty Dental Program Claim Form	Form 5579	Active Duty Dental Program Claim Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	300,000	0	0	123,000	0	177,000
Annual Time Burden (Hours)	75,000	0	0	60,250	0	14,750
Annual Cost Burden (Dollars)	1,308,000	0	0	1,308,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a change in burden because this is a reinstatement with updated burden and cost estimates.

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Annual Cost to Federal Government: $1,800,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/21/2016

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