Information Collection

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

IC 43597 under ICR 201808-0720-001 · OMB 0720-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0006 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Form and Instruction
2642 TRICARE DoD/ CHAMPUS Medical Claim Patient's Request for DD 2642 Draft 20180829.pdf www.esd.whs.mil/Directives/forms/	Form and Instruction

IC Title:

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

Agency IC Tracking Number:

0720-0006

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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 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

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 830,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	830,000	56,000	774,000
Annual IC Time Burden (Hours)	207,500	14,000	193,500
Annual IC Cost Burden (Dollars)	1,504,375	-3,487,925	4,992,300

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.