Active Duty Dental Program Claim Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0053 can be found here:

Documents and Forms

Document Name Document Type
Form Form 5579 Active Duty Dental Program Claim Form Form
Form 5579 Active Duty Dental Program Claim Form Proposed ADDP_Claim_Form_072413_reader.pdf secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Active Duty Dental Program Claim Form	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	Form 5579	Active Duty Dental Program Claim Form	Proposed ADDP_Claim_Form_072413_reader.pdf	https://secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm	Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title: Medical/Dental Claim History Files	FR Citation: 80 FR 65720

Number of Respondents: 75,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300,000	123,000	177,000
Annual IC Time Burden (Hours)	75,000	60,250	14,750
Annual IC Cost Burden (Dollars)	1,308,000	1,308,000	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.