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

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

OMB: 0720-0006

IC ID: 43597

Information Collection (IC) Details

View Information Collection (IC)

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment 0720-0006
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 2642 TRICARE DoD/ CHAMPUS Medical Claim Patient's Request for Medical Payment DD 2642 Draft 20180829.pdf http://www.esd.whs.mil/Directives/forms/ Yes Yes Fillable Fileable Signable

Defense and National Security Operational Defense

 

830,000 0
   
Individuals or Households
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 830,000 0 0 56,000 0 774,000
Annual IC Time Burden (Hours) 207,500 0 0 14,000 0 193,500
Annual IC Cost Burden (Dollars) 1,504,375 0 0 -3,487,925 0 4,992,300

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.

© 2024 OMB.report | Privacy Policy